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PubMed1999

Advance directives for mental health treatment.

Advance directives are designed to establish a person's preferences for treatment if the person becomes incompetent in the future or unable to communicate those preferences to treatment providers. Mental health advance directives are similar to the more commonly used directives for end-of-life medical decisions. A patient must be competent to execute a mental health advance directive, and the directive must clearly express the patient's wishes. Once directives are executed, steps must be taken to ensure compliance, including adequate dissemination to providers, and to ensure that proxy decisions are consistent with the patient's treatment preferences. Potential effects of mental health advance directives include enhanced consumer empowerment; improved functioning; improved communication between consumers, family members, and providers; increased tolerance for consumer autonomy at the organizational level in community mental health agencies; and reduced use of hospital services and judicial proceedings. Issues to be clarified in future research and practice include strategies for increasing awareness of advance directives in mental health, barriers to execution of legally and clinically effective directives, practitioners' concerns, providers' compliance with directives, effects of directives on consumers and providers, effects of managed care on implementation of directives, and stakeholders' perceptions of the value of directives.

Advance Care Planning↗
PubMed1991

The Patient Self-Determination Act and the future of advance directives.

Living wills and other advance directives currently play a limited role in medical decision making. A new federal law, the Patient Self-Determination Act, will require health care providers in hospitals, nursing homes, and other facilities to inquire about the presence of advance directives, to record patient preferences in the medical record, and to develop institutional policies regarding the implementation of these directives. Unfortunately, the law does little to promote discussion or preparation of advance directives before hospitalization. Additional efforts to promote the use of advance directives can take place in the outpatient medical care system, in attorneys' offices, or through health insurers. Because most people have not yet prepared an advance directive, we suggest that institutions develop treatment policies for situations in which the wishes of patients who lack decisional capacity are not known. These policies should be designed to promote the patients' best interests, as defined by the consensus of the institutions' staff and members of the surrounding community.

Advance Directives↗
PubMed2002

Patients' attitudes toward advance directives.

PURPOSE: To explore hospitalized patients' attitudes toward advance directives, their reasons for completing or not completing advance directive forms, and demographic differences between patients who did and did not complete advance directive forms. DESIGN AND METHOD: The convenience sample comprised 30 hospitalized patients in North Carolina. Participants were interviewed using an adapted advance directive attitude survey (ADAS), and were asked five general questions about advance directives. Validity and reliability were established on the adapted tool. FINDINGS: The overwhelming majority of participants had received information on advance directives and they were moderately positive about them. The majority who had completed advance directives were Caucasian, female, over age 65, had less than a high school education, and perceived their health as poor. Most believed that an advance directive would ensure they received the treatment they desired at the end of life. CONCLUSIONS: Patients' attitudes alone did not determine who will and will not complete advance directives. Most participants who completed advance directives had specific reasons for doing so. Nurses have responsibility for discussing advance directives with patients, families, and physicians to ensure adequate education about the completion of advance directives.

Adult↗
PubMed1995

Advance directives: do they work?

Advance directives have been widely endorsed, and empiric work has taken place that can aid clinicians in the appropriate use of validated documents. This report reviews philosophic and methodologic issues and offers practical illustrations. Despite the evidence that advance directives can work, there are serious barriers to their actual use. Therefore, these barriers are evaluated and potential solutions suggested.

Advance Directive Adherence↗
PubMed2000

Advance directives in critically ill cancer patients.

Although advance directives have been used since the 1970s, the discussion of these documents has become more common since the enactment of the Patient Self-Determination Act in 1991. This study evaluated the frequency of advance directives in critically ill patients at a tertiary cancer center and found that cancer patients had a relatively low completion rate of advance directives (27%). The finding that advance directives were more common among Caucasians than other ethnic groups signifies the importance of considering cultural differences when addressing end-of-life issues with patients. The documents also were found more often in older patients with serious diseases. The relationship between hospital mortality and advance directives is complex. The most seriously ill patients and patients with leukemia had the highest mortality and the highest rate of advance directives. Further research on the interactions among mortality, advance directives, and severity of illness is needed. This research contributes to the body of knowledge available on advance directives and particularly sheds light on advance directives in critical ill cancer patients.

Adult↗
PubMed1996

The importance of advance directives in primary care.

The advance directive has been acknowledged widely by patients and physicians as a desirable tool to promote patient autonomy at the end of life. Rates of completion of advance directives, however, remain low among all segments of the population. Significant patient and physician barriers to completion of advance directives are considered. Legal and ethical principles of advance directives, as well as some practical means of overcoming barriers to these important discussions, are reviewed.

Advance Directives↗
PubMed1999

Advance directives.

Different types of advance directives invite varying interpretation from emergency care professionals. As informed consent of a patient is not always possible to procure in emergency situations, advance directives can provide useful guidelines for clinicians' decision-making processes regarding individual patient care. Specifically communicated instructions establish a course of aggressive or nonaggressive treatment, while general wishes leave the emergency department physician to assume an innate understanding of individual patients while undertaking an active role in decision-making for that patient's care. This article explores the relationship between advance care directives and the emergency department.

Advance Directives↗
PubMedDate not supplied

Advance directives in cardiac and pulmonary rehabilitation patients.

PURPOSE: Advance directives have been available in parts of the United States for more than 20 years, but research shows that only a small percentage of adults (5-25%) have some form of written advance directive. The purose of this study was to examine the presence of advance directives among persons entering cardiac and pulmonary rehabilitation, and identify characteristics of persons most likely to have advance directives. METHODS: The sample consisted of 336 cardiac patients and 181 pulmonary patients who enrolled in the University of Alabama at Birmingham's Cardiopulmonary Rehabilitation Program between January 1996 and December 1999. As part of the initial program assessment, patients were asked two questions: (1) Do you have a living will? (2) Do you have any advance directives? For the purposes of this study, the two questions were combined to examine the presence of either a living will or other type of advance directive. RESULTS: Results indicate that 25% of both subgroups (cardiac and pulmonary patients) report having written advance directives. Logistic regression analysis indicates that among cardiac patients whites and older persons were more likely to have advance directives. Among pulmonary patients, females and whites were more likely to have advance directives. CONCLUSIONS: These results indicate that only a minority of cardiopulmonary rehabilitation patients have advance directives upon entry into the program, and that the prevalence differs among gender, racial, and age groups. Cardiac and pulmonary rehabilitation programs may be valuable sites for educating patients about advance directives and efforts by rehabilitation personnel may increase the prevalence of advance directives among patients.

Adult↗
PubMed2005

Advance directives: the New Zealand context.

Advance directives convey consumers' wishes about accepting or refusing future treatment if they become incompetent. They are designed to communicate a competent consumer's perspective regarding the preferred treatment, should the consumer later become incompetent. There are associated ethical issues for health practitioners and this article considers the features that are relevant to nurses. In New Zealand, consumers have a legal right to use an advance directive that is not limited to life-prolonging care and includes general health procedures. Concerns may arise regarding a consumer's competence and the document's validity. Nurses need to understand their legal and professional obligations to comply with an advance directive. What role does a nurse play and what questions arise for a nurse when advance directives are discussed with consumers? This article considers the cultural dimensions, legal boundaries, consumers' and providers' perspectives, and the medical and nursing positions in New Zealand.

Advance Directives↗
PubMedDate not supplied

CQI in policy implementation: advance directives.

Recognition of patients' rights is growing in the healthcare field in this country, as is recognition of the need for advance directives. Advance directives are documents that indicate treatment choices and preferences made by an individual while he or she is still competent. Through the use of continuous quality improvement (CQI) tools and the development of a CQI team, the author's facility was able to implement the important process of having patients complete advance directives.

Advance Directives↗
PubMed1993

Advance directives. Effect of type of directive on physicians' therapeutic decisions.

BACKGROUND: Despite growing support for advance directives, there are few data validating their utility. We conducted this study to determine if the type of advance directive influences physicians' willingness to withhold specific therapies and if physicians are equally willing to withhold these therapies. METHODS: The 444 full-time faculty of the department of medicine of a university medical center were presented with patient scenarios and accompanying advance directives in three separate surveys that were mailed. They were asked if they would withhold each of 12 specific therapies based on their interpretation of the advance directive. Three types of advance directives were studied: general statement, therapy specific, and therapy specific combined with designation of a proxy and prior patient-physician discussion. RESULTS: The mean proportion of all 12 therapies that were withheld varied by type of advance directive: general-statement advance directive, 55%; therapy-specific advance directive, 71%; and therapy-specific advance directive with proxy and prior patient-physician discussion, 83%. Respondents were more likely to withhold cardiopulmonary resuscitation when given a therapy-specific advance directive vs general-statement advance directive, 84% vs 73%, respectively. With a therapy-specific advance directive that was supported by a proxy and prior patient-physician discussion, 100% of physicians were willing to withhold cardiopulmonary resuscitation. With the therapy-specific advance directive that was supported by proxy and prior patient-physician discussion, physicians were not equally willing to withhold all therapies, ie, mechanically assisted ventilation, 98%; intravenous fluids, 82%; antibiotics, 80%; simple tests, 70%; and pain medications, 13%. CONCLUSIONS: Detailed advance directives with a supportive proxy, coupled with physician-patient discussion, furnish the most reliable medical directives. Even with such directives, physicians are more likely to withhold life-saving therapies than simple tests, treatments, and pain medications.

Advance Directive Adherence↗
PubMed2004

Current legal status of advance directives in the United States.

Advance directive legislation has been in place throughout much of the United States for nearly 3 decades. The right to give an informed consent to or refusal of medical treatment has been recognized by state and federal courts, and that right has been determined to survive the loss of decisional capacity and may be exercised through the execution of instructional or proxy directives. Despite these developments, the percentage of the adult population with a formal advance directive of any type has never exceeded 15%. Moreover, a remarkable number of these directives are ambiguous and/or their existence is unknown to the physicians who are expected to rely upon them. Even unambiguous directives may not be followed at the critical stage in the trajectory of a patient's illness, and the accountability for such disregard by health care institutions or professionals is negligible to nonexistent. Nevertheless, there is real potential for advance directives, as a key element to sound advance care planning, to fulfill their initial promise as instruments of the prospective autonomy of patients. In order for that potential to be realized, primary care physicians must embrace advance care planning as a part of their professional responsibility to patients.

Advance Directives↗
PubMed1993

Effect of an educational program on medical students' conversations with patients about advance directives: a randomized trial.

Advance directives, such as the durable power of attorney for health care (DPAHC), help patients and physicians make end-of-life health care decisions. Medical education should prepare student physicians to be knowledgeable about and comfortable with discussing advance directives. The authors developed an educational module for the third-year medical school curriculum and conducted a randomized trial to evaluate in students its effect on various outcome measures regarding the DPAHC. Over a six-week period, students who received written material about the DPAHC and a two-hour seminar significantly increased knowledge about and reported increased skill, comfort, and experience with the DPAHC.

Adult↗
PubMed1993

Advance directives and living wills.

Advance directives are documents which enable people to decide what will happen to them, or who will make decisions on their behalf, if a time comes when they are no longer able to participate in discussions or decisions about their own health care. This paper briefly examines the underlying philosophy of advance directives, and the manner in which they have evolved in the United States. It concludes by considering their legal status in the United Kingdom which, until recently, was not entirely clear.

Advance Directives↗
PubMed1999

Psychiatric wills of mental health professionals: a survey of opinions regarding advance directives in psychiatry.

Psychiatric wills are advance directives for an eventual involuntary treatment in psychiatry. We attempted to determine psychiatric professionals' knowledge and opinion about this legal option and obtain their formulations of advance directives for themselves. A total of 101 psychiatric nurses and psychiatrists at the Department of Psychiatry of the University of Vienna responded to a questionnaire about psychiatric wills and anonymously drafted advance directives for themselves concerning psychiatric treatment in case of an acute psychosis. Fifty-four percent knew about this legal option, 55% considered it an appropriate legal possibility, and 29% considered it inappropriate. The study also found that 75% of respondents reject certain methods of therapy, e.g. 30% want to exclude the use of neuroleptic medications, and 46% reject ECT. We conclude that although there is little experience so far with advance directives for psychiatric patients, there is an interest and predominance of positive attitudes towards this legal option among mental health professionals. Concerning their preferences, professionals felt inclined to make very specific statements as to which available treatment strategies they would reject and which they would request for their treatment. This bodes well for the widespread use of advance directives in mental health settings.

Adult↗
PubMed2005

Would they follow what has been laid down? Cancer patients' and healthy controls' views on adherence to advance directives compared to medical staff.

UNLABELLED: Advance directives are propagated as instruments to maintain patients' autonomy in case they can no longer decide for themselves. It has been never been examined whether patients' and healthy persons themselves are inclined to adhere to these documents. Patients' and healthy persons' views on whether instructions laid down in advance directives should be followed because that is (or is not) "the right thing to do", not because one is legally obliged to do so, were studied and compared with that of medical staff. METHOD: Vignette study presenting five cases. Cancer patients, healthy persons, nursing staff and physicians (n = 100 in each group) were interviewed. An adherence score was calculated (maximum value 5). The adherence score is found to be low in all groups, yet lowest in patients (1.55; standard deviation 1.13) and healthy controls (1.60; 1.37). The scores are significantly different between nursing staff on the one hand and patients and healthy controls on the other (p < 0.005 and p < 0.05, respectively), and between doctors and patients (p < 0.05). Interviewees who want these documents to be followed tend to live alone and to have already written an advance directive. CONCLUSIONS: Cancer patients and healthy persons widely disregard instructions laid down in advance directives and consider them less binding than physicians and nursing staff do. Only a minority tends to adhere more to advance directives. To improve decision-making at the end of life when patients are no longer able to decide for themselves alternative concepts, such as advanced care planning, should be considered.

Adult↗
PubMed2004

Predictors of site of death of end-of-life patients: the importance of specificity in advance directives.

Despite the compelling reasons for advance directives and their endorsement by the public and medical professions, little is known about their actual use and impact on site of death. This study was conducted to examine the role of advance directives and other "drivers" of hospitalization of the long-term care end-of-life patient. The medical records of 100 deceased consecutive nursing home residents, stratified by site of death (skilled nursing facility or acute care hospital), were reviewed by a team of geriatric researchers to obtain patient information in the following domains: sociodemographic, advance directives, transfer and death information, patient diagnoses at admission, discharge, and other time intervals; medication usage and signs and symptoms precipitating death. Severity of illness was assessed using the Cumulative Illness Rating Scale-G (CIRS-G). In testing for differences between patients by site of death, sociodemographic variables (gender, age, race, payer at discharge, cognitive capacity) did not significantly differ between the two groups of patients. Strong similarities between the groups were also found in terms of severity of illness and medication usage. Significantly higher proportions of patients dying in the nursing home had specific advance directives (do not resuscitate, do not intubate, do not artificially feed, do not hydrate, and do not hospitalize), as opposed to those dying in the hospital. The findings of this study demonstrate the impact of the explicit advance directive on the decision to transfer the patient to the acute care setting at the end of life.

Advance Directives↗
PubMedDate not supplied

The patient self-determination act and advance directive completion in nursing homes.

OBJECTIVES: To assess the prevalence of advance directives among nursing home residents before and after passage of the Patient Self-Determination Act (PSDA) and to identify factors associated with advance directive completion. DESIGN: Prestudy and poststudy nursing home admissions using medical record reviews and a companion cross-sectional survey of alert and oriented residents. SETTING: Six nursing homes in Connecticut. PARTICIPANTS: Residents (N = 635) from 6 randomly chosen nursing homes in the greater Hartford and greater New Haven areas. MAIN OUTCOME MEASURES: The existence of a documented advance directive, the timing of advance directive completion, and reported reasons for completion and noncompletion. RESULTS: The prevalence of advance directives documentation in nursing home medical records has increased significantly since the implementation of the PSDA (4.7% [14/300] before vs 34.7% [104/300] after PSDA; odds ratio, 10.84; P < .001). The increase in documented advance directives was significant after controlling for sociodemographic and health status factors (odds ratio, 11.5; P < .001). Residents admitted to the nursing homes from hospitals (vs from their home or other source), residents with more education, and residents paying privately for nursing home care (vs using Medicare or Medicaid benefits) were more likely to have documented advance directives. Younger residents (aged < 75 years) were less likely than older residents to have completed a directive. Among the 35 interviewed residents, the most common reason for completing an advance directive was experience with a prolonged death of a friend or family member. Only 1 of the interviewed residents reported that the information provided under the PSDA at the time of admission was an important factor in choosing to complete an advance directive. CONCLUSIONS: Nearly 35% of the residents in the post PSDA cohort had an advance directive documented in the medical record. Most residents with advance directives had completed them more than 6 months before the nursing home admission. The major effect of the PSDA for nursing homes has been to enhance the documentation of existing advance directives. Little evidence exists that providing advance directive information at the time of nursing home admission has enhanced the completion of an advance directive after admission.

Advance Care Planning↗