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At least 19 recordsLinked to original sources
PubMed1992

Advance directives.

Advance directives concerning treatment have been firmly established in our society. Reactions to them, however, are varied, especially when the health care provider possesses a different belief about the care, or non-provision of care, in a particular situation. It is important for the neuroscience nurse to be in touch with thoughts and feelings concerning a patient's treatment choice, and, when necessary, to seek input and support about those concerns. Clearly, if the nurse cannot carry out the patient's wishes, the nurse can use applicable state law provisions supported by the Patient Self-Determination Act, and request not to participate in the care of that patient. If, however, the neuroscience nurse does provide care, ethically and legally it must be done in accordance with the patient's expressed choices.

Advance Directives↗
PubMedDate not supplied

After Cruzan: the "values base" to advance directives.

Technologic advances produce ethical quandaries for health care professionals and the public. Often difficult decisions must be made about treatment. In light of the 1990 U.S. Supreme Court's ruling in the case of Nancy Cruzan, health care decisions surrounding life-sustaining treatment may be affected. National attention is refocused on advance directives (the living will and durable power of attorney for health care decisions). This article considers the possible need for additional "clear and convincing" evidence of the patient's wishes regarding these directives. Included is a Value History Form that provides an avenue of expression for patient values and beliefs.

Advance Directives↗
PubMed1992

Advance directives.

Explore the source record for details and available documents.

Advance Directives↗
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↗
PubMed1991

Advance directives for medical care--a case for greater use.

UNLABELLED: BACKGROUND. Advance directives for medical care and the designation of proxy decision makers to guide medical care after a patient has become incompetent have been widely advocated but little studied. We investigated the attitudes of patients toward planning, perceived barriers to such planning, treatment preferences in four hypothetical scenarios, and the feasibility of using a particular document (the Medical Directive) in the outpatient setting to specify advance directives. METHODS: We surveyed 405 outpatients of 30 primary care physicians at Massachusetts General Hospital and 102 members of the general public in Boston and asked them as part of the survey to complete the Medical Directive. RESULTS: Advance directives were desired by 93 percent of the outpatients and 89 percent of the members of the general public (P greater than 0.2). Both the young and the healthy subgroups expressed at least as much interest in planning as those older than 65 and those in fair-to-poor health. Of the perceived barriers to issuing advance directives, the lack of physician initiative was among the most frequently mentioned, and the disturbing nature of the topic was among the least. The outpatients refused life-sustaining treatments in 71 percent of their responses to options in the four scenarios (coma with chance of recovery, 57 percent; persistent vegetative state, 85 percent; dementia, 79 percent; and dementia with a terminal illness, 87 percent), with small differences between widely differing types of treatments. Specific treatment preferences could not be usefully predicted according to age, self-rated state of health, or other demographic features. Completing the Medical Directive took a median of 14 minutes. CONCLUSIONS: When people are asked to imagine themselves incompetent with a poor prognosis, they decide against life-sustaining treatments about 70 percent of the time. Health, age, or other demographic features cannot be used, however, to predict specific preferences. Advance directives as part of a comprehensive approach such as that provided by the Medical Directive are desired by most people, require physician initiative, and can be achieved during a regular office visit.

Advance Directives↗
PubMed1991

Getting advance directives to the public: a role for emergency medicine.

Advance directives are becoming more common in the health care system in the United States. Advance directives include "living wills," "durable powers of attorney for health care," "do not resuscitate orders," and the newer "medical directive." They are designed to allow individuals to determine the course of their medical care in the event that they are no longer able to transmit the information to their physician. The US Supreme Court's recent Cruzan decision increased the importance of these legal instruments by declaring that "clear and convincing" evidence may be required by states in order to terminate life support in a patient unable to express his wishes about care. Unfortunately, for many reasons, advance directives are often not completed by those who might desire them. Only 9% of Americans have executed advance directives. Emergency physicians have the opportunity to assist their patients in advance by disseminating advance directives to those who have contact with the emergency department: patients, family members, friends, health care workers, emergency medical services personnel, and police. A plan is suggested that includes education, the availability of advance directives, personnel available to help with completion of the documents, and immediate entry of the directive into a medical chart, if requested. This is in conformance with a recent policy adopted by the American College of Emergency Physicians.

Advance Directives↗
PubMed1992

Empowerment of the older patient? A randomized, controlled trial to increase discussion and use of advance directives.

OBJECTIVE: To see if an educational intervention directed at older outpatients would lead to increased use or discussion of advance directives and to characterize patients' reasons for not obtaining advance directives. DESIGN: Randomized, controlled trial of an educational intervention versus usual care. SETTING: Outpatient geriatrics clinic of a university hospital. PATIENTS: One hundred and thirty-one non-demented patients over the age of 65 who did not have an advance directive documented in their record at the start of the study. Forty-eight patients were in the trial arm and 83 in the control. MAIN OUTCOME MEASURES: All patients had their charts reexamined 6 months after enrollment to look for the presence of a living will, a durable power of attorney for health care, or a physician's note describing a discussion of advance directives. Trial patients were also re-interviewed to examine their reasons for not executing an advance directive. MAIN RESULTS: Six months after the intervention, only seven of the 48 trial subjects (15%) had an advance directive or note describing discussion of advance directives in their charts compared to eight of the 83 controls (10%) (P greater than 0.05). When asked to give reasons for not obtaining an advance directive, many patients' responses pointed to procrastination as a significant barrier. CONCLUSIONS: Promoting advance directive use is a complicated task. Barriers other than information and access to documents appear to be involved and need to be addressed in future efforts.

Advance Directives↗
PubMed1992

Effects of offering advance directives on medical treatments and costs.

OBJECTIVE: To examine the effects of advance directives on medical treatments and on patient satisfaction and well-being and to determine whether the enhancement of patient autonomy through advance directives provides a more ethically feasible approach to cost control than does the imposition of limits through rationing. DESIGN: Randomized, controlled trial. SETTING: University and Veterans Affairs medical center. PATIENTS: Two hundred and four patients with life-threatening illnesses, 100 of whom died after enrollment in the study. INTERVENTION: Patients randomly assigned to the experimental group were offered the California Durable Power of Attorney (a typical proxy-instruction directive), and patients assigned to the control group were not offered the advance directive. Hospital admissions were monitored to assure that a summary of the document was present in the active medical record at each hospitalization. MEASUREMENTS: Cognitive function, patient satisfaction, psychological well-being, health locus of control, sense of coherence, health-related quality of life, receipt of medical treatments, and medical treatment charges. RESULTS: No significant differences were found between advance-directive and control groups regarding psychosocial variables, health outcome variables, and medical treatments or charges. Patients offered an advance directive had an average hospital stay of 40.8 days (95% CI, 32.2 to 49.4 days), compared with an average of 33.1 days (95% CI, 26.0 to 40.2 days) for controls. Patients offered an advance directive were charged an average of $19,502 (95% CI, $13,030 to $25,974) for medical treatments in the last month of life compared with $19,700 (95% CI, $13,704 to $25,696) for controls. CONCLUSIONS: Despite claims that public demand for longer life accounts for rising medical costs, most surveys suggest that patients are calling for less, not more, of the expensive, high-technology treatment often used in terminal phases of illness. Executing the California Durable Power of Attorney for Health Care and having a summary copy placed in the patient's medical record had no significant positive or negative effect on a patient's well-being, health status, medical treatments, or medical treatment charges.

Advance Directives↗
PubMed1992

Advance directives provide answers for tough questions.

Will advance directives provide an effective means of assuring that previously written decisions will be honored by health care providers if the patient becomes incompetent or terminally ill? This and other questions are posed in the following article. The Patient Self-Determination Act of 1990 mandates that all health care providers receiving federal reimbursement for services provide information to each patient and offer the option of executing an advance directive for health care decisions. The author presents an overview of two studies about advance directives as reported in the New England Journal of Medicine.

Advance Directives↗
PubMed1992

Family physicians' attitudes toward advance directives.

OBJECTIVE: To examine the attitudes toward, the experience with and the knowledge of advance directives of family physicians in Ontario. DESIGN: Cross-sectional survey. PARTICIPANTS: A questionnaire was mailed to 1000 family physicians, representing a random sample of one-third of the active members of the Ontario College of Family Physicians; 643 (64%) responded. RESULTS: In all, 86% of the physicians favoured the use of advance directives, but only 19% had ever discussed them with more than 10 patients. Most of the physicians agreed with statements supporting the use of advance directives and disagreed with statements opposing their use. Of the respondents 80% reported that they had never used a directive in managing an incompetent patient. Of the physicians who responded that they had such experience, over half said that they had not always followed the directions contained in the directive. The proportions of physicians who responded that certain patient groups should be offered the opportunity to complete an advance directive were 96% for terminally ill patients, 95% for chronically ill patients, 85% for people with human immunodeficiency virus infection, 77% for people over 65 years of age, 43% for all adults, 40% for people admitted to hospital on an elective basis and 33% for people admitted on an emergency basis. The proportions of physicians who felt that the following strategies would encourage them to offer advance directives to their patients were 92% for public education, 90% for professional education, 89% for legislation protecting physicians against liability when following a directive, 80% for legislation supporting the use of directives, 79% for hospital policy supporting the use of directives, 73% for reimbursement for time spent discussing directives with patients and 64% for hospital policy requiring that all patients be routinely offered the opportunity to complete a directive at the time of admission. CONCLUSIONS: Family physicians favour advance directives but use them infrequently. Most physicians support offering them to terminally or chronically ill patients but not to all patients at the time of admission to hospital. Although governments emphasize legislation, most physicians believe that public and professional education programs would be at least as likely as legislation to encourage them to offer advance directives to their patients.

Adult↗
PubMed1992

Caring for older cancer patients: practical decision-making guidelines with a focus on advance directives.

There are no simple solutions to difficult ethical problems. Advance directives, however, offer a way to help prevent ethical dilemmas from occurring in the care of older cancer patients. Studies show that there is overwhelming support from both older patients and physicians for advance treatment planning through the use of living wills, durable powers of attorney for health care, and less formal means. Despite this support, few physicians and patients discuss advance directives. This paper discusses potential barriers to this dialogue and suggests specific ways to incorporate advance directive into routine cancer care of older patients. The Patient Self-Determination Act of 1990 represents additional pressure from society on the medical profession to carry out advance directive discussions.

Advance Directives↗
PubMed1992

How strictly do dialysis patients want their advance directives followed?

OBJECTIVE: The Cruzan case and the Patient Self-Determination Act will encourage patients to specify in advance which life-sustaining treatments they would want if they become mentally incompetent. However, strictly following such advance directives may not always be in a patient's best interests. We sought to determine whether patients differ in how strictly they want advance directives followed. DESIGN: Interview study. SETTING: Seven outpatient chronic dialysis centers. PARTICIPANTS: One hundred fifty mentally competent dialysis patients. INTERVENTION: Using a structured questionnaire, we asked the subjects whether they would want dialysis continued or stopped if they developed advanced Alzheimer's disease. We then asked how much leeway their physician and surrogate should have to override that advance directive if overriding were in their best interests. Subjects granting leeway were also asked what factors should be considered in making decisions for them. RESULTS: Subjects varied greatly in how much leeway they would give surrogates to override their advance directives: "no leeway" (39%), "a little leeway" (19%), "a lot of leeway" (11%), and "complete leeway" (31%). Subjects also varied in how much they wanted various factors considered in making decisions, such as pain or suffering, quality of life, possibility of a new treatment, indignity caused by continued treatment, financial impact of treatment on family members, and religious beliefs. CONCLUSIONS: Strictly following all advance directives may not truly reflect patients' preferences. To improve advance directives, we recommend that physicians explicitly ask patients how strictly they want their advance directives followed and what factors they want considered in making decisions.

Adolescent↗
PubMed1991

A prospective study of advance directives for life-sustaining care.

BACKGROUND: The use of advance directives is recommended so that people can determine the medical care they will receive when they are no longer competent, but the effectiveness of such directives is not clear. METHODS: In a prospective study conducted over a two-year period, 126 competent residents of a nursing home and 49 family members of incompetent patients were interviewed to determine their preferences with respect to hospitalization, intensive care, cardiopulmonary resuscitation, artificial ventilation, surgery, and tube feeding in the event of critical illness, terminal illness, or permanent unconsciousness. Advance directives, consisting of signed statements of treatment preferences, were placed in the medical record to assist in care in the nursing home and to be forwarded to the hospital if necessary. RESULTS: In an analysis of 96 outcome events (hospitalization or death in the nursing home), care was consistent with previously expressed wishes 75 percent of the time; however, the presence of the written advance directive in the medical record did not facilitate consistency. Among the 24 events in which inconsistencies occurred, care was provided more aggressively than had been requested in 6 cases, largely because of unanticipated surgery or artificial ventilation, and less aggressively than requested in 18, largely because hospitalization or cardiopulmonary resuscitation was withheld. Inconsistencies were more likely in the nursing home than in the hospital. CONCLUSIONS. The effectiveness of written advance directives is limited by inattention to them and by decisions to place priority on considerations other than the patient's autonomy. Since our study was performed in only one nursing home and one hospital, other studies are necessary to determine the generalizability of our findings.

Adult↗
PubMed1992

Predictors of advance directive restrictiveness and compliance with institutional policy in a long-term-care facility.

OBJECTIVE: To ascertain factors influencing the level of advance directives selected by nursing home residents or surrogates and the time delay to documentation of these choices in the medical record after implementation of a facility-wide policy. DESIGN: Longitudinal cohort study of nursing home residents followed from date of advance directive policy initiation or time of admission for a maximum of 21 months from study commencement. SETTING: A 315-bed multilevel nursing home. PARTICIPANTS: Four hundred twenty-four nursing home residents (mean age 85, 74.9% female, 96.1% white). OUTCOME MEASURES: Level of advance directive status chosen--full code, do not resuscitate (DNR) or palliative care only--and date documented in the medical record. RESULTS: Factors predictive of restricted advance directives (DNR or palliative care) included age greater than 85 years (P = 0.025), documented use of a surrogate decision maker (P = 0.001), low physical function (P less than 0.001), low cognitive function (P less than 0.001), and having a nursing home-employed physician (P = 0.001). These results were confirmed using logistic regression models. Median time to directive documentation decreased from 54 days for residents admitted in the first quarter to 1 day for residents admitted in the fourth quarter of the year following initiation of an advance directive policy. CONCLUSION: In logistic models, nursing home-employed physicians were more likely to write restricted advance directive orders than community-based physicians even after controlling for resident age, cognitive status, and physical function. In addition, implementation of a formal nursing home advance directive policy can shorten time to physician documentation of resident advance directive status.

Activities of Daily Living↗
PubMed1991

Federal advance directives legislation: potential effects on emergency medicine.

On December 1, 1991, a new federal law designed to increase public use of advance directives takes effect. After that date, health care facilities must provide written information about advance directives to all adult patients. This information must describe (1) the patient's rights to make medical care decisions under state statutes and case law, and (2) how patients can secure these rights within the scope of the provider's policies. The law also requires that institutions educate their staffs and the communities about advance directives and document the existence of any advance directive in the patient's medical record. The new federal law will benefit American society, U.S. health care, and the practice of emergency medicine. However, emergency physicians should anticipate that the law will provide not only benefits, but also some burdens. Many institutions will expect emergency department personnel to disseminate and explain the required information, and annotate the medical record. It is the specialty's responsibility to gather empirical data that can guide the use of advance directives in emergency departments.

Adult↗