A prospective study of advance directives for life-sustaining care

Article Abstract:

Advance directives, or living wills, are documents that individuals prepare while of sound mind to specify what life-sustaining treatments they would accept or would not want used. Although these documents are now widely advocated, their effectiveness has not been evaluated. To learn more about this issue, a prospective two-year study of 175 residents of a nursing home in North Carolina (126 of whom were competent) was carried out. Patients (or their surrogates, if they were incompetent) were interviewed to determine their preferences regarding how much treatment should be offered in several kinds of situations (hospitalization, intensive care, cardiopulmonary resuscitation, tube feeding), and their responses were reformulated into a set of statements that were signed by the patient and inserted prominently into the nursing home chart. The nursing home was visited regularly to determine whether deaths or hospitalizations had occurred and the treatments that were offered. There were 35 deaths and 71 hospitalizations during the study (106 outcome events). The nursing home charts contained the advance directives for 74 percent of the 106 events, but the document was delivered to the hospital in only 25 of the 71 hospitalizations. In 72 of the 96 events for which such data were analyzed, medical treatment was in accordance with the advance directives. In the 24 events where the directives were not followed, the majority (18) involved delivery of less aggressive care than preferred. There was less consistency between patients' wishes and the care they received when the advance directive was in the medical record than when it was not. Patients treated in the nursing home were four times as likely to receive care not in accordance with their wishes than those treated in the hospital. Although the care patients received often fit their wishes, it was not because of the advance directive. It appears that such documents do not guide treatment decisions; however, far from indicating that they are useless, the findings indicate that these documents should be improved. (Consumer Summary produced by Reliance Medical Information, Inc.)

Care and treatment, Research, Nursing home patients

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Do-not-resuscitate orders at a teaching hospital in Japan

Article Abstract:

Adaptation of a formal do-not-resuscitate (DNR) policy by Japanese hospitals would help develop patient-centered care of patients near the end of life. Researchers at a Japanese teaching hospital created and evaluated DNR guidelines and a standard DNR form. During the study year, 56 of 443 admitted patients had DNR orders. Of the 67 patients who died in the hospital, 48 (72%) had DNR orders. Most of the decisions to write DNR orders involved the patient's physician and a family member, but not the patient. The primary reasons for writing DNR orders were family request, and probability of death within two weeks or six months. The percentage of patients with DNR orders was similar to that in other countries, but patient involvement in DNR decisions was lower in Japan. This difference in patient involvement may be caused by Japanese patients not knowing their diagnosis, a lack of published DNR guidelines, and a tendency of patients to trust their doctors with decisions.

Health aspects, Planning, Japanese, Japanese (Asian people), CPR (First aid), Cardiopulmonary resuscitation

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Beyond advance directives - health care surrogate laws

Article Abstract:

Some patients are not capable at the end of their life to make decisions about their medical care for various reasons. Family members of these individuals often find it difficult to carry out the patient's wishes. An individual can draft an advance directive while still healthy to delineate their end-of-life wishes. Despite enactment of the Patient Self-Determination Act in Dec 1991, very few people prepare advance directives. Some states have enacted legislation to appoint surrogate decision makers for patients who are incapacitated. This legislation enables the state to appoint a friend or relative to make medical decisions for patients without an advance directive or durable power of attorney. Patients' physicians are responsible for deciding whether they are incapacitated and qualify for a surrogate. Under these laws, family and friends will be able to request discontinuation of life-sustaining treatment.

Usage, Innovations, Column, Advance directives (Medicine), Medical care decision-making authority (Law), Medical care decision making authority (Law)

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