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Advance directives support the concepts of patient autonomy and resource allocation. Promotion of advance directives by nurse managers according to the suggested paradigm should be an economic and policy priority.
In the last decade the use of advance directives or living wills has become increasingly common. This paper is concerned with those advance directives in which the user opts for withdrawal of active treatment in a future situation where he or she is incompetent to consent to conservative management but where that incompetence is potentially reversible. This type of directive assumes that the individual is able accurately to determine the type of treatment he or she would have adopted had he or she been competent in this future scenario. The paper argues that this assumption is flawed and provides theoretical and empirical evidence for this. If the assumption is false, and those taking out advance directives do not realise this, then the ethical bases for the use of these advance directives-the maximisation of the individual's autonomy and minimisation of harm-are undermined. The paper concludes that this form of advance directive should be abolished.
This study reported a lower than expected prevalence of advance directives among hospice patients. The presence of an advance directive was related to certain sociodemographic factors, diagnosis, and previous physician-patient advance directive discussions. Barriers that precluded the completion of an advance directive primarily involved a lack of physician-patient advance directive discussions or a lack of patient understanding. This study confirmed the importance of physician-patient discussion toward completion of an advance directive. Improving physician-patient communication about this issue should increase the prevalence of advance directive completion among hospice patients.
Hospitals need to assure themselves that advance directives are available to caregivers, especially physicians, and that the patient's wishes expressed in them are being followed. This can be done only with data collection and analysis and improvement of the processes that support availability and use of advance directives. On a broader, societal perspective, it has been suggested that wide-spread use of advance directives such as natural death act declarations might encourage systematic rationing of healthcare to the elderly. If a right to die becomes a duty to die, the living will and its progeny, the natural death act declaration, will have become a Frankenstein monster. Indeed, in the mid-1980s the suggestion by then-governor Richard Lamm of Colorado, as well as officials at Health and Human Services that the elderly should be required to have living wills raised a storm of protest. Regardless of true motives, such suggestions are often seen as motivated by economics. The hospital must be alert to the ethical issues of advance directives, which are present regardless of a natural death act statute or a living will. Hospitals and their managers must consider these issues prospectively and develop policies that enable them to respect and meet patients' wishes, consistent with the organizational philosophy.
CONTEXT: Although advance directives are commonly used in the community, little is known about the effects of their systematic implementation. OBJECTIVES: To examine the effect of systematically implementing an advance directive in nursing homes on patient and family satisfaction with involvement in decision making and on health care costs. DESIGN: Randomized controlled trial conducted June 1, 1994, to August 31, 1998. SETTING AND PARTICIPANTS: A total of 1292 residents in 6 Ontario nursing homes with more than 100 residents each. INTERVENTION: The Let Me Decide advance directive program included educating staff in local hospitals and nursing homes, residents, and families about advance directives and offering competent residents or next-of-kin of mentally incompetent residents an advance directive that provided a range of health care choices for life-threatening illness, cardiac arrest, and nutrition. The 6 nursing homes were pair-matched on key characteristics, and 1 home per pair was randomized to take part in the program. Control nursing homes continued with prior policies concerning advance directives. MAIN OUTCOME MEASURES: Residents' and families' satisfaction with health care and health care services utilization over 18 months, compared between intervention and control nursing homes. RESULTS: Of 527 participating residents in intervention nursing homes, 49% of competent residents and 78% of families of incompetent residents completed advance directives. Satisfaction was not significantly different in intervention and control nursing homes. The mean difference (scale, 1-7) between intervention and control homes was -0.16 (95 % confidence interval [CI], -0.41 to 0.10) for competent residents and 0.07 (95% CI, -0.08 to 0.23) for families of incompetent residents. Intervention nursing homes reported fewer hospitalizations per resident (mean, 0.27 vs 0.48; P = .001) and less resource use (average total cost per patient, Can $3490 vs Can $5239; P = .01) than control nursing homes. Proportion of deaths in intervention (24%) and control (28%) nursing homes were similar (P = .20). CONCLUSION: Our data suggest that systematic implementation of a program to increase use of advance directives reduces health care services utilization without affecting satisfaction or mortality.
BACKGROUND: Despite the fact that advance directives are legal documents that allow people to direct their future health care, few Americans have enacted them. Because lack of knowledge about what they are, and confusion regarding the process needed to complete one are the primary barriers for completion, patient education can be the key element in promoting the use of advance directives. CONCLUSION: This article offers some teaching strategies nurses may use to address patients' ignorance and confusion and help patients understand that, although advance directives do not help people make end-of-life decisions, they serve as a mechanism by which a person's wishes may be carried out.
Using advance directives to preconsent to mental health treatment is a promising approach to contending with the quandary posed by patients suffering from severe mental health illness, particularly those in a prison setting. The implementation of advance directives represents unfamiliar territory because it focuses on the patient's ability to preconsent to treatment rather than the commonly interpreted prerefusal of treatment. The challenge of consenting in the prison system generates a set of unique problems. The environment in which the instrument is signed can impose significant pressures and therefore result in a viable legal challenge. The prison setting is the most coercive environment in which a patient can be treated, particularly when the patient is mentally ill. Mentally ill prisoners signing preconsent for treatment advance directives have an opportunity for unprecedented relief yet may also experience pressure to select treatments desirable to the prison staff.
The effects of advance care planning are poorly understood. The purpose of this study was to evaluate the effect of an advance care planning intervention on the completion of advance directives (ADs) and patient satisfaction. A volunteer sample of persons with HIV/AIDS received advance directive documents, watched an educational video and received individual counselling on completing an advance directive during three face-to-face interviews over approximately six months. The advance care planning intervention was associated with an increase in advance directive completion rates from 16.4% to 40.7% (p = 0.001), but 23.1% of advance directives reported as completed were legally invalid. There was a trend towards decreased overall patient satisfaction with health care (p = 0.07). Advance are planning increases the rate of AD completion but many 'completed' advance directives are legally invalid. Advance care planning did not improve patient satisfaction with health care.
This article considers 2 major critiques of advance directives and offers a defense to each of them. The 1st critique is philosophical in nature and maintains that the moral authority of an advance directive is undercut by a failure of personal identity to survive the loss of decisional capacity. The response in this article is that this critique relies on a flawed and disfavored concept of persons and their persistence over time. The 2nd critique, pragmatic in nature, argues that advance directives cannot be authoritative because the requisite elements of an informed consent to or refusal of treatment are rarely present, and many such instruments are ambiguous. The author argues that if the creation of advance directives, as a form of advance care planning, is made an integral aspect of clinical practice, many more patients will elect to execute directives, and those directives will not be ambiguous.
BACKGROUND: It has been assumed that patients using advance directives would direct terminal care away from the intensive care unit and choose shorter, less costly, less technological terminal hospital stays. METHODS: This retrospective cohort study examined 336 consecutive patients who died in a university tertiary care medical center: 242 without advance directives, 66 with a previously completed advance directive, 13 admitted for the express purpose of terminal care, and 15 who signed an advance directive during their terminal hospitalization. Total charges (hospital and physician) were calculated for all patients and were adjusted using both physician and hospital diagnosis-related group weights. Patient participation in end-of-life decisions was determined by chart review. RESULTS: The group without advance directives had dramatically higher mean total ($49,900 vs $31,200) terminal hospitalization charges than the group with previously completed advance directives, producing a charge ratio of 1.6. After diagnosis-related group adjustment, the charge ratio was 1.35 (95% confidence interval, 1.07 to 1.72) for physician charge, 1.36 (95% confidence interval, 1.06 to 1.74) for hospital charge, and 1.35 (95% confidence interval, 1.08 to 1.73) for total charge. Multiple regression analysis controlling for age, sex, and cancer diagnosis confirmed these findings. Patients with advance directives were significantly more likely to limit treatment and to participate in end-of-life decisions. CONCLUSION: Patients without advance directives have significantly higher terminal hospitalization charges than those with advance directives. Our investigation suggests that the preferences of patients with advance directives are to limit care and these preferences influence the cost of terminal hospitalization.
Advance directives (ADs) are instructions from patients to their physician and family regarding their wishes for medical care in the event they become incapable of communicating those wishes. This study sought to describe the characteristics of adults who have completed advance directives and those who have expressed interest in them, and to determine what distinguishes these groups from the group with no interest in ADs. A further objective was to survey the study population on the barriers to completion of ADs. A random sample of 160 outpatients visiting one of three clinics (General Internal Medicine Clinic (GIM), HIV Clinic, and Oncology Clinic) were selected for the study. A 10-item questionnaire was administered which included questions on familiarity with, sources of information on, and interest in ADs. Demographic information was collected as well as information on subject experiences with illness and death. Twenty-six of the 160 participants (16%) had completed ADs. The prevalence of completion differed among the three clinics: HIV Clinic 25%, Oncology Clinic 18%, and GIM Clinic 8%. Nearly all patients (95%) expressed interest in ADs. Those not interested in ADs were more likely than those who were interested or those who had already completed ADs to have been in an intensive care unit themselves. Multiple barriers to completing ADs were identified. Advance directives are still used by relatively few people despite a general openness and interest in them. Few characteristics, demographic and otherwise, were identified to distinguish those who completed ADs from those who did not.
BACKGROUND: Age, illness severity, functional status, and education are associated with advance directive completion. We examined these patient characteristics and discussions with attorneys and physicians in a predictive model for advance directive completion. METHODS: We did a cross-sectional survey of 255 randomly selected patients in a VA outpatient clinic. RESULTS: Patients were predominantly men (95.2%), married (61.9%), with a mean age of 63.2 years; 17.7% of the patients had an advance directive; 5.0% had only a living will, 6.0% had only a durable power of attorney for health care, and 6.7% had both. Age, marital status, illness severity, previous serious illness in spouse, and physician discussion were all associated with advance directive completion in a multiple logistic regression. Eighty-two patients were asked about discussions with attorneys--15 had advance directives; of these, 13 had talked to an attorney, but only 7 had talked to a physician. CONCLUSIONS: Previous serious spousal illness, marital status, age, illness severity, and patient-physician discussions all predicted completions of an advance directive. Attorney discussions were strongly associated with advance directive completion. Better communication between physicians, patients, and attorneys may increase the usefulness of advance directives.
Much of the patient education about advance directives described in the literature involves explaining the purpose of advance directives to patients and guiding them through the process of issuing a directive. However, well over half of the subjects in this study claimed to know enough about the directives to issue one, and almost all subjects expressed a preference for issuing directives when healthy. Although health care agencies that wish to adhere to the PSDA must continue to ask all patients if they have issued an advance directive, aggressive patient education programs that press hospitalized patients to consider issuing an advance directive may be perceived by patients as coercive and uncaring. Patient education may be more likely to achieve the goals of the PSDA if it is provided before hospitalization and if patients are encouraged to discuss their care preferences with family members who would be in a position to speak for them at the end of life. Further study of the few patients who choose to issue an advance directive would be informative. When and why they chose to issue the directive should be explored. Patients who report issuing an advance directive but do not provide their physician or hospital with a copy of the directive upon admission should also be studied to determine if this represents a desire not to activate the directive during the current admission or simply confusion about the disposition of this document. Finally, most studies of advance directives have been cross-sectional. Longitudinal study of patients who issue advance directives are needed to determine the effectiveness of these documents in influencing the end-of-life treatment that patients receive.
BACKGROUND: Some have suggested that advance directives elicit goals of care from patients, instead of or in addition to specific intervention preferences, but little is known about whether goals of care can be used in a meaningful way on documents or whether they can predict preferences for specific interventions. METHODS: Attending physicians (n = 716) at the Massachusetts General Hospital in Boston were surveyed to elicit general goals of care (eg, treat everything or comfort measures only) along with specific preferences for 11 medical, interventions in 6 scenarios. In each scenario, each goal was classified as an adequate predictor of acceptance or rejection of an intervention if its predictive value of the preference for that intervention was at least 80%. RESULTS: Goals varied with scenarios (P < .001) in a predictable manner. The goal treat everything was an adequate predictor of acceptance of each intervention, and comfort was an adequate predictor of rejection for nearly every intervention. Attempt cure adequately predicted acceptance of almost every nonaggressive intervention, but did not predict acceptance of aggressive interventions. Quality of life predicted rejection of aggressive interventions in 3 scenarios, but was not useful in other cases. When goals were predictors of preferences, the mean range of 95% confidence intervals for their predictive values was generally 20% or less. CONCLUSIONS: Goals have a valid role in advance directives, since the goal choices had a logical relationship to scenarios and intervention choices. However, the 2 goals attempt cure and choose quality of life were not predictive in many instances. If these findings hold true for more general populations of patients, then advance directive documents will need to rely on more than these general goal statements if they are to adequately represent patient preferences.
The development of the Values History instrument for use in advance directive decision making has raised the question of the importance of values in eliciting advance directives. This pilot study examines the relationship between the domains of values and advance directives drawn from the Values History in three generation intrafamily triads. Significant correlations between values and advance directives were found primarily within the youngest generation. Results reveal a relatively high familiarity by the participants of the various established forms of advance directives. Also, a significant percentage of parents and grandparents was found to have signed some form of advance directive.
UNLABELLED: A review of medical charts of all deaths for one year at a general acute care hospital reveals that 135/602 (22%) charts indicate that the patient had an advance directive. In 68/135 (50%) of the cases, the patients were unable to participate in decisions and met the conditions of the advance directive. In 33/68 (49%) of those cases the records indicate that the advance directive influenced care. In 63 of the 135 charts the advance directive was present and chart notations indicate an additional 25 advance directives were located at the physician's office. Eighteen of a total of 44 physicians listed as attending accounted for the 33 cases in which the record indicates that the advance directive was recognized. Twelve of these 135 patients were coded during their hospitalization. Three of the 12 were coded in the ER upon admission, the remaining 9 were coded in the course of their care in the acute care hospital. Regarding code status a three tiered (Cat I, II, III) classification system was in place. Initial classification of the 135 patients upon admission was: 64 "full code" (I), 56 were "all but CPR" (II), 15 were "No code" (III). Code classification at the time of death (or discharge) was: I = 45, II = 53, III = 36. OBJECTIVE: To investigate the extent to which advance directives influence clinical care of patients during the final acute hospitalizations. DESIGN: Retrospective chart review. SETTING: General Hospital of 274 beds. PATIENTS: 602 death charts reviewed, 135 contained indications or the execution of an advance directive. MAIN OUTCOME MEASURES: The 1995 medical records of 602 death were reviewed for evidence of influence of advance directives in clinical care. RESULTS: 24% of patients who had advance directives in the chart or at the physicians office had their directives recognized during their final hospitalization. In 68/135 (50%) of the cases the conditions to activate the advance directive were met. And in 33/68 (49%) of those cases the advanced directive was invoked. There was some, but less than expected correlation between advanced directives and DNR orders. In a three tiered Code Category Classification system (Cat. I, full code, Cat. II Chemical Code, Cat. III, No Code.) the initial classifications in the 135 cases with evidence of advance directives were Cat. I 47%, Cat. II 42%, and Cat. III 11%. Compared to 59 cases where there was no indication of an advance directive the classifications were Cat. I 67%, Cat. II 26% and Cat. III 7%. However, the classifications in the two groups at the time of death of the patients were Cat. I 34% & 31%, Cat. II 39% & 39% and Cat. III 27% & 30%. There was a 20% increased incidence of an initial classification of full code in the cases without indication of an advance directive. But once the patient care involved review of code status, the final classifications of patients were the same irrespective of the presence of an advance directive. CONCLUSIONS: In 50% or 68/135 of the cases the patient met the conditions for invocation of the advance directive and in 33 or 49% of those cases the advance directive was invoked. Another way to state the impact of advance directives in the population studied is that in 22% of the 602 deaths there was indication of an advance directive and in 50% of those cases the directive became relevant and in 49% of those cases it had a bearing on the care (or in 5% of the 602 death studied). More research is needed to determine why advance directives are not utilized more and why they to do not have greater effect on clinical care decisions in terminal patients. But problems with making them available to relevant parties, hospital record keeping, and physician recognition of their significance are evident.
Growing evidence suggests that advance directives (ADs) are often ineffective. Further explanation of how these documents are viewed by the public, the expectations of how decisions about treatment are made, and, in particular, patients' understanding of how ADs are actually used in the clinical setting, are warranted. This article details a descriptive study in which patients were interviewed, during hospital stays, about their beliefs and understanding of advanced directives, as well as the processes used in completing them. The study was undertaken in a community hospital located in a rural area in the Midwest. Findings show that many patients were able to clearly articulate what an AD means in terms of making their choices known. However, misconceptions were found in patients' understanding of ADs and only 46% reported discussing their ADs with a physician. Strategies for effective implementation of education programs related to ADs are detailed here.
OBJECTIVE: To examine the effects of an advance directive videotape on patient comprehension of advance directive concepts and preferences for resuscitation. DESIGN: Pilot study, randomized cohort trial. SETTING: Extended Care and Rehabilitation Center, Veterans Affairs Medical Center, Durham, NC. PARTICIPANTS: Thirty-six residents of the center; mean age, 69 years. INTERVENTIONS: Sixteen subjects observed an advance directive videotape, and 20 subjects observed a health-relative videotape. All subjects received written material and counseling on advance directives. MEASUREMENT: Structured interviews were conducted at three time points relative to the educational program (pretest, posttest, delayed posttest), measuring comprehension of two advance directive concepts (living will and cardiopulmonary resuscitation) and resuscitation preferences based on hypothetical clinical vignettes. Mean comprehension and mean resuscitation preference scores were derived for each time point. RESULTS: The mean comprehension score improved an average of 1.6 points for all subjects from pretest to delayed posttest (P < .001); however, score changes were not significantly different between the two video groups (P = .39). Mean resuscitation preference scores were stable over time, and there were no significant score differences between the two video groups. CONCLUSION: The advance directive videotape did not significantly affect resuscitation preferences or comprehension of selected advance directive concepts.