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At least 19 recordsLinked to original sources
PubMed2003

Willing and able. Supreme Court ruling forces HMOs to open networks to any willing provider; some say it may wound managed-care industry.

In a decision some say could help end traditional managed care, the U.S. Supreme Court ruled that states have the power to force HMOs to open their networks to any healthcare provider willing to abide by the plans' terms. Elizabeth Johnson, left, counsel for the Kentucky Department of Insurance, says the decision will let states take on key healthcare issues that Congress has never been able to resolve.

Contracts↗
PubMed1998

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↗
PubMed2002

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↗
PubMed1995

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↗
PubMed1996

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↗
PubMed1993

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↗
PubMed2003

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↗
PubMedDate not supplied

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↗
PubMedDate not supplied

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↗
PubMedDate not supplied

Daily torpor in free-ranging whip-poor-wills (Caprimulgus vociferus).

The use of heterothermy is well documented in the order Caprimulgiformes, but there is conflicting information regarding whether whip-poor-wills are heterothermic. Consequently, we sought to rigorously examine the thermoregulatory abilities of this species. Our study was conducted in southeast South Dakota (42 degrees 47'N, 97 degrees 0'W), where 35 individuals were captured and outfitted with external, temperature-sensitive radio transmitters. We found evidence that whip-poor-wills used daily torpor during the autumn of 2000 and the spring of 2001 (n=12 torpor bouts, based on 346 bird-nights of observation). The average minimum skin temperature of two torpid whip-poor-wills (n=5 torpor bouts) in spring 2001 was 20.1 degrees +/-2.6 degrees C, and bouts of reduced skin temperature lasted an average of 360.0+/-93.7 min. The distribution of heterothermy within the Caprimulgiform phylogeny suggests that the trait is ancestral in the order. Specific heterothermic parameters, however, differ among the different species. In particular, the frequency of torpor use in whip-poor-wills is lower than for other species. These data suggest that several factors, including weather conditions and gender-specific reproductive ecology, influence the propensity of whip-poor-wills and other Caprimulgiformes to enter torpor.

Animals↗
PubMed1996

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↗
PubMed1992

Factors associated with veterans' decisions about living wills.

Most states have adopted legislation that allows patients to designate by advance directives the type of health care they would like to receive if they should become incompetent while suffering from a terminal illness. The living will is one of the most common of these legal instruments. Unlike most studies that have examined very sick or hospitalized patients' preferences regarding life-sustaining treatments, our study explores the concerns of 70 ambulatory veterans from a general medical clinic regarding living wills. Before the interview, 43% of patients reported never having heard of living wills. At interview, 4% of the patients had a living will, 33% intended to sign a living will but had not done so (INTEND), 54% were undecided about living wills (UNDECIDED), and 9% did not want a living will. Compared with UNDECIDED patients, all other patients did not differ in the use of health care services during the previous year or in diagnoses. INTEND patients, however, were significantly more likely to be white, to express poorer health status, to know someone with a living will, and to have previously discussed the topic. UNDECIDED patients were more likely than INTEND patients to report that religious beliefs about living wills affected their decision. Virtually all (91%) of the respondents believed that signing a living will would not affect their treatment. These data suggest that many patients may not know that they can have a living will and that discussions with those who already have a living will may be helpful in educational programs designed to promote informed patient decision-making.

Aged↗