Wills, living wills and enduring powers of attorney.
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Should living wills be legalized?
Living wills allow patients to state their wish to die and not be kept alive through the use of medications, artificial means or "heroic" measures. They have been made legal documents in 38 states in the United States. Living wills permit advance expression of a patient's wishes, promote effective communication and demonstrate respect for the patient as a person. Problems with legal recognition of such wills include the need for agreement on fundamental terms, possible restriction of patients' rights, limitation of options in decision-making and possible negative effects on the physician-patient relationship. Before legislation is enacted, public and professional attitudes toward the care of terminally ill patients should be assessed. All health care professionals should receive better education in this area, and palliative care services should be made more widely available. Only if these measures fail should living wills be made legal documents in Canada.
Attitude of Health Personnel↗
Patient, physician, and family member understanding of living wills.
This study examines understanding of living wills by patients, family members, and physicians. Questionnaires were used to examine whether each cohort understood patients' living wills regarding endotracheal intubation and cardiopulmonary rescuscitation (CPR). Of 4,800 patients admitted during the study period, 206 reported having living wills, all of which precluded intubation and CPR for "terminal conditions." Of 140 admitted to the general hospital wards, 17 (12%) wanted their living wills to preclude intubation/mechanical ventilation and 12 (8.6%) did not want resuscitation under any circumstances. Seven of 120 (6%) physicians and 4 of 108 family members would not intubate or perform CPR even if there was a chance of recovery. Of 88 patients with complete data (including physicians and family members), 29 (33%) wanted their living wills to block intubation/mechanical ventilation only if they were deemed terminal and 46 (52%) wanted the living will to block intubation even if there was a 10% chance of recovery. Thirteen (15%) wanted to block intubation even if the chance of recovery was > or = 50. Results were similar for wishes regarding CPR. These data suggest substantial differences of patient, physician, and family member understanding of living wills. Living wills did not reflect fully patients' expectations of receiving (or not receiving) life-sustaining modalities.
Adult↗
Living wills and resuscitation preferences in an elderly population.
BACKGROUND: Living wills are considered clear and convincing evidence of a person's preferences for end-of-life treatment. Unfortunately, living wills often use vague language that forces physicians and others to infer specific treatment choices, like the choice to forgo cardiopulmonary resuscitation (CPR). To test the validity of such inferences we examined the relationship between living will completion and CPR preference. We also examined whether CPR choices were fixed or could be influenced by detailed information on CPR. METHODS: We interviewed 102 retired elderly persons, many of whom had living wills. We obtained CPR preferences in five hypothetical scenarios before and after providing CPR information. We then analyzed differences in desire for CPR between the group of subjects with living wills and the group without. RESULTS: In each scenario there were subjects in both groups who desired CPR. The group with living wills desired less CPR in scenarios involving functional impairment and cognitive impairment, but not in scenarios involving current health, severe illness, and terminal illness. After receiving CPR information, both groups changed their preferences such that intergroup differences were no longer seen. CONCLUSIONS: Preferences for CPR among subjects with living wills are not homogeneous, but distributed across the clinical scenarios. Therefore, one cannot infer CPR preference from the mere presence of a living will. Cardiopulmonary resuscitation information can influence preferences even among persons with living wills, implying that preferences are neither fixed nor always based on adequate information. Physicians should view vaguely worded documents as unreliable expressions of treatment preference that should not supplant informed discussion.
Aged↗
Outpatients' attitudes and understanding regarding living wills.
OBJECTIVE: To assess outpatients' attitudes toward and understanding of a standard living will. DESIGN: Survey using a self-administered questionnaire that patients completed after they had read a sample living will. SETTING: General medicine clinic of a Department of Veterans Affairs medical center. PATIENTS: Two hundred fourteen patients (85% of those approached) attending a continuity care clinic appointment. Eighty-seven percent were men; mean age was 60 years. MEASUREMENTS AND MAIN RESULTS: Patients' attitudes toward living wills, understanding of the terminology contained in living wills, desire to discuss living wills with their doctors, and desire to prepare a living will. RESULTS: Seventy-two percent of the patients had prior knowledge of living wills, though only 53% had discussed the topic with family members and only 14% with physicians. Half felt that the living will terminology should be simplified, and 55% were unable to identify the correct definition for at least one commonly used term. Desire to prepare a living will was positively associated with better understanding of the sample document and previous knowledge of and exposure to living wills, and was negatively associated with concern about its use and revocability (all p < 0.001). Patients who reported poor understanding of the living will were more likely to want to discuss the topic with a physician (p < 0.01). CONCLUSIONS: In this ambulatory patient population attitudes toward living wills were influenced by knowledge and understanding of these documents. Primary care physicians and institutions should develop patient education strategies that enhance understanding of advance directives.
Attitude to Death↗
Advance directives and living wills.
Under certain circumstances, living wills or advance directives may carry legal force in the UK. This paper traces the development of advance directives, clarifies their current legal position and discusses potential problems with their use. Case histories are used to illustrate some of the common dilemmas which doctors may face.
Adolescent↗
Do general practitioners know when living wills are legal?
BACKGROUND: There is growing public awareness of living wills or advance directives. Patients who wish to make advance directives may approach general practitioners (GPs) for advice. However, many GPs are unaware of the correct legal status of living wills. METHODS: Questionnaires were sent to 270 GPs in London and Winchester, asking seven questions about the current legal status of living wills. RESULTS: Of the 214 GPs (79%) who returned questionnaires, only 104 (49%) were aware that some types of advance directives could carry legal force. Many of the GPs who did know that living wills could be legally binding were unable correctly to answer further questions on the practicalities of the law; for example, 26% were wrong in believing that a lawyer had to draw up a living will, and 13% incorrectly believed that a doctor was legally required to give any treatment requested by a patient in a living will. CONCLUSIONS: Half of the GPs surveyed were unaware that living wills currently have legal force and most of the rest were unaware of important details of the law. More attention needs to be given to the education of doctors in this area.
Advance Directives↗
The use of living wills at the end of life. A national study.
BACKGROUND: Knowing more about who uses living wills may help explain their limited acceptance. METHODS: We analyzed the 1986 National Mortality Followback Survey, a random sample of all US deaths linked to a survey about decedents' use of living wills, their social and health status, and their use of medical services. Decedents with and without living wills were compared for differences in social and health characteristics and use of medical services. RESULTS: There were 16,678 decedents; 9.8% had a living will. Rates of use were higher for decedents who were white (10.7%), were female (11.0%), had private insurance (13.8%), had incomes of $22,000 or more (14.5%), or had college educations (18.7%). The use of living wills was lower among blacks (2.7%), Medicaid recipients (6.3%), those with incomes of less than $5,000 (7.5%), or those with less than 8 years of education (4.0%). Health was also related to use of living wills. Functionally independent persons were unlikely to have a living will (5.5%); use increased with dependency. Cognitive impairment made it less likely that a decedent had a living will (6.7%). Persons who died of cancer (16.4%) or pulmonary disease (11.4%) were more likely to have one. All demographic and health characteristics remained significant in multivariate analyses. Controlling for health status, decedents with living wills used more physician visits (five to nine vs two to four, P < .001) and hospital days (37 vs 30, P < .001). Although more likely to use hospices (19.5% vs 8.4%, P < .001) and half as likely to receive cardiopulmonary resuscitation or ventilatory support, they were still 20% more likely to die in the hospital. CONCLUSIONS: Patients who are black, poorly educated, underinsured, or cognitively impaired are least likely to prepare a living will. Decedents with living wills forgo specific treatments, but remain intensive users of routine medical services.
Cardiopulmonary Resuscitation↗
Nurses' knowledge, experiences, and attitudes concerning living wills.
A random sample of 974 registered nurses in Nova Scotia were surveyed during the 1995-96 registration year to determine their understanding of living wills legislation; their experiences, roles, and attitudes related to living wills; and their perceptions of the barriers to and resources for using living wills in their practice. Responses from 157 nurses indicated that they were unfamiliar with the Medical Consent Act, the Hospitals Act, and the Powers of Attorney Act. Although they revealed that they had a positive attitude towards living wills, and they identified nurses as the appropriate health professional to initiate discussions about living wills with patients, very few had any actual experience in this role. Respondents rated their understanding of living wills as low, and many indicated that they were uncomfortable discussing the topic with clients. Respondents saw both the individual nurse and the practice environment as barriers to the use of living wills, and they clearly indicated the need for interdisciplinary educational strategies to facilitate the use of living wills in their nursing practice.
Adult↗
Knowledge, attitudes, and behavior of elderly persons regarding living wills.
The knowledge, attitudes, and behavior of elderly persons regarding living wills were explored in a rural county in eastern North Carolina. A questionnaire was administered to 75 ambulatory elderly persons by personal interview at community dining sites. Fifty-two percent (39) of these subjects said they were familiar with living wills and 64% (48 persons) correctly summarized what the North Carolina living will says. When asked about preferences for medical care in the setting of a terminal illness, 86% (65 persons) stated a desire to receive basic medical care or comfort care only. Although their preferences were consistent with the provisions of a living will, none had signed the living will document provided by the state of North Carolina, and only two (3%) had discussed a living will with their physician. Seventy (93%) wanted their family or spouse to make decisions about terminal care if they themselves were unable to participate, and discussions between these persons and their chosen proxies actually occurred 45% (34/75) of the time. Eighty-one percent (61 persons) stated a desire to discuss end-of-life care with their physicians, but a minority (eight [11%]) had actually talked with their physicians, and these discussions were usually initiated by the patient (five of eight). We conclude that living will legislation is congruent with the desire of many elderly persons to limit medical care in terminal illness. However, this elderly population did not make use of living wills as a means of indicating their wishes. Recommendations are made to improve physician-patient and patient-proxy communication regarding preferences for medical care at the end of life and living wills. Alternatives to the living will should also be explored.
Aged↗
Living wills and the Mental Capacity Act: a postal questionnaire survey of UK geriatricians.
OBJECTIVE: To determine geriatricians' experience of and views on living wills, National Health Service Trusts' support of advance end-of-life health care planning and geriatricians' views on related legal changes in the Mental Capacity Act. DESIGN: Anonymous postal questionnaire survey of all 1,426 British Geriatrics Society members in England, Wales and Northern Ireland. RESULTS: A total of 842 (59%) questionnaires were returned. Of 811 geriatricians, 454 (56%) had cared for patients with living wills. Of the 280 who cared for patients when the living will had come into effect, 108 (39%) had changed treatment because of the living will and 84 (78%) of those felt that decisions had been easier to make. Living wills not already in effect made discussions with patients [171 of 178 (96%)] and families [135 of 178 (76%)] easier. Of 779 geriatricians, 713 (92%) saw advantages of older people using living wills; 467 of these also expressed concerns. Only 16 (2%) geriatricians who had concerns said that there were no advantages. A total of 214 (27%) were aware that their Trust had a form to help with discussions about cardiopulmonary resuscitation. Fewer [126 of 781 (16%)] were aware of a Trust policy on living wills. The proposal, in the Mental Capacity Bill, for advance refusals of treatment was supported by 59% (476 of 801), yet the proposal for a lasting power of attorney (LPA) covering health care was only supported by 47% (382 of 806). CONCLUSION: Many geriatricians have positive experiences of caring for patients with living wills. Despite recognising potential problems, most geriatricians support the use of living wills by older people. However, most believe that their Trust does not have a policy to support advance health care planning. Geriatricians have reservations about LPAs covering health care.
Advance Directive Adherence↗
Physicians's reports on the impact of living wills at the end of life in Japan.
CONTEXT: A growing number of Japanese people have completed advance directives, especially living wills, even though there is no legislation recognising such documents and little empirical research on their impact on clinical care at the end of life in Japan. OBJECTIVES: To investigate physicians' attitudes about living wills and their experiences with patients who had completed a living will and later died. DESIGN: Self administered survey and qualitative study using open question and content analysis. SETTING: Japan. PARTICIPANTS: Physicians known to have cared for a patient who had presented a living will prior to death. MEASUREMENTS: The physician's response to receiving a living will, communication about the living will, the impact of the living will on clinical care, demographics, and their opinion on advance directives, especially living wills. MAIN RESULTS: Fifty five per cent of respondents approved of advance directives in general, and 34% had more opportunities to communicate with a patient and his/her family after receiving the living will. Sixty nine per cent of the physicians who received a living will did not, however, change their course of therapy as a consequence of receiving the living wills. Based on the analysis, we identified three areas of concern in the comments on living wills: (1) concerns relative to patients, physicians, and families; (2) social context, and (3) clinical and administrative concerns. The physicians raised various topics for discussion; they tended to describe the issues from a clinical perspective. CONCLUSIONS: Our identified areas of concern should prove helpful in better understanding the clinical and ethical implications of living wills in Japan.
Advance Directive Adherence↗
Second thoughts on living wills.
Advance directives such as living wills are attractive in that they give us a sense of control over our futures. But they also tend to obscure conflicts between a patient's competent wishes and later, incompetent interests. They allow caregivers to avoid evaluating quality of life in assessing the best interests of incompetent patients.
Caregivers↗
Life values, resuscitation preferences, and the applicability of living wills in an older population.
OBJECTIVES: To determine whether life values are related to resuscitation preferences and living will completion in an older population and to assess beliefs about the applicability of living wills. DESIGN: Individual structured interviews. SETTING: An independent retirement community. PARTICIPANTS: One hundred thirty-two subjects older than 63 years of age. MEASUREMENTS: Resuscitation preferences were elicited in five hypothetical scenarios. Subjects with living wills were asked whether their living will would play a role in the scenarios. Subjects rated the importance of 13 life value statements. RESULTS: The percentage of subjects desiring CPR in each scenario was as follows: current condition (66%); acute illness (33%); terminal disease (8%); functional impairment (8%); and dementia (7%). The percentage of those with a living will who thought their living wills would play a role in the scenarios was as follows: acute illness (84%); terminal disease (93%); functional impairment with intact cognition (66%); and dementia (91%). Factor analysis of the life value statements revealed five meaningful factors: quality of life; capacity/autonomy; family relations; physical comfort; and treatment philosophy. Multiple correlations were found between four of five life value factors and hypothetical resuscitation preferences or the presence of a living will. CONCLUSION: Subjects misinterpreted the applicability of living wills in nonterminal illness scenarios. A relationship between life values and resuscitation preferences was noted, which emphasizes the importance of eliciting and including life values when discussing advance directives.
Aged↗
Iowa nurses' knowledge of living wills and perceptions of patient autonomy.
The principle of patient autonomy is well recognized in the nursing profession. This study extends the exploration of patient autonomy by examining nurses' knowledge about living wills. The questions addressed in this study included the following: (1) Were Iowa nurses aware of the living will statute? (2) What sources of information did nurses use to learn about this legislation? (3) What were nurses' perceptions of patients' rights? (4) What were nurses' perceptions of nurses' role involving living wills? (5) Were living wills followed? (6) If not followed, which factors contributed to the failure to honor a living will? and (7) Which communication mechanisms were used to alert nurses to a living will? A questionnaire was mailed to 10,000 actively licensed nurses in Iowa. Approximately 3,000 Iowa nurses responded to the questionnaire regarding Iowa living wills. Seventy per cent of the nurses knew that Iowa had living will legislation. No single educational source was a predominate choice for targeted information about the living will statute. Nurses were reluctant to suggest to patients that they should consider writing a living will. Nurses were also more willing to assume a passive role of suggesting that patients talk with relatives about the need for a living will but were less likely to be suggest that a patient write a living will for future health care treatment decisions. The majority of the nurses favored the patient having some control in health care treatment decisions. Three major factors were pertinent to the failure to follow a living will: family request, treating physician's refusal, and lack of information that the living will existed. The medical record was the primary means of communication regarding a living will. To enhance patient efforts at self-determination, nurses must recognize the advance directive legislation is available in their state and the potential impact that their nursing care may have on the implementation of the document.
Adult↗
Are living wills useful? In search of a new paradigm.
Living wills are written by patients to direct physicians and loved ones as to the medical care they want in the event of catastrophic illness that is accompanied by inability to communicate their wishes. We outline recent data suggesting that living wills are poorly understood by patients who have them and that the usefulness of these documents in the clinical arena is extremely limited. Potential solutions for current deficiencies in end-of-life care and decision-making are discussed.
Connecticut↗
Discussing living wills. A qualitative study of a German sample of neurologists and ALS patients.
Patients suffering from amyotrophic lateral sclerosis (ALS) eventually lose their ability to communicate their treatment preferences in later stages of the disease. A living will enables ALS patients to specify their choices concerning life-sustaining treatment in advance. Our premise was that completion of a living will should be preceded by a discussion between patient and physician. We conducted a qualitative study of a sample of 15 neurologists and 15 ALS patients from two neurology centers in Germany. Our aim was to explore how discussions about living wills are undertaken. Data analysis followed grounded theory techniques. Our findings showed that both the patients and the physicians considered living wills to be closely connected to forthcoming death. Physicians waited for respiratory failure to occur before they informed ALS patients about living wills, an information strategy that we called the "wait-and-see-policy". The patients completed their living will when they had accepted the hopelessness of their disease. They mostly used living will forms and did not see the necessity to set down disease-specific preferences. They intended to wait for symptoms to emerge before they made the decision about whether or not to accept life-sustaining treatment. The patients as well as the physicians pursued a wait-and-see policy towards end-of-life care, thus weakening the purpose of living wills. Our results point to the necessity and importance of an open and honest patient-physician communication which is a prerequisite for the discussion of living wills.
Adolescent↗
Living wills: how do they inform care?
Recent publicity about living wills has heightened nurses' awareness about the growing number of patients and clients completing them. However, there appears to be considerable confusion and growing anxiety about the legality of living wills as documents, the authority they have in informing care, and the role of health-care professionals in using them.
Decision Making↗