Advance directives for medical care - a case for greater use

Article Abstract:

Advance directives or living wills (documents that specify what, if any, life-sustaining treatments a patient wants) are often enthusiastically endorsed, but research has shown that they are infrequently used; only 9 percent of the subjects in one study had drawn up such documents. To learn more about the reasons most people do not complete advance directives, a study was carried out of 405 outpatients and 102 members of the general public contacted via telephone survey. Subjects completed an eight-part questionnaire which covered their health status, perceived barriers to and knowledge about advance directives, sample scenarios (for example, coma) and their anticipated responses, and the effects of the survey on their thinking about living wills. Responses showed that most subjects (93 percent of outpatients, 89 percent of the general public) expressed a desire for some form of planning; however, only 15 percent of the outpatients and 18 percent of the general public had actually drawn up a form of advance directive. The barriers most often mentioned to completing advance directives were patients' expectations that physicians would take the initiative, and the feeling that such matters were more relevant for older people or those in poor health. The proportion of patients who said they would refuse treatment of specific types is listed; overall, approximately 70 percent would have refused life-sustaining treatment if they became incompetent with an irreversible condition. Respondents' preferences did not fit obvious patterns with respect to demographic factors (age) or health status. The obstacles to formulating advance directives, something desired by most people, could be overcome by physicians. The fact that patients' wishes cannot be inferred based on demographic or health factors underscores the importance of individualized planning. Using standardized forms, an advance directive can be completed in 15 minutes or less. It is suggested that the costs for such an office visit be reimbursed by third-party payers. (Consumer Summary produced by Reliance Medical Information, Inc.)

Research, Management, Physician and patient, Physician-patient relations

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Proxy decision making for incompetent patients: an ethical and empirical analysis

Article Abstract:

Adults who are incompetent may need to have a family member act as a proxy (surrogate) to make decisions about their medical care. Family members have traditionally been expected to make decisions for incompetent patients by physicians and the courts. A legal precedent was established when a court appointed Karen Quinlan's father the authority to refuse medical care for her. Many states have subsequently enacted statutes that endorse proxy decision making. Family members may be most qualified to make decisions for incompetent patients because they know the patient's wishes, and they are concerned for the patient's welfare. But proxy decision making may only approximate the patient's wishes, and family members may have interests that conflict with the patient's. Research studies have found that proxies may have difficulty assessing the patient's wishes. The debate about decision-making for incompetent adults may be resolved by giving the family the right to make these types of decisions for family members. Or, individuals could complete advance care documents that appoint a proxy and state treatment preferences. Another solution is to establish community standards that set guidelines for caring for incompetent patients.

Health aspects, Decision making, Patients, Capacity and disability, Proxy, Decision-making (Ethics)

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The Medical Directive: a new comprehensive advance care document

Article Abstract:

Over the last decade the use of living wills has been supported by the courts, lawyers, government and physicians. Despite all this support, they are seldom used because of technical defects which render them vague and difficult to apply. A new advance care document, the Medical Directive, has been delineated to more clearly define the method of treatment that should be extended, based on the patient's previously delineated preferences, to the patient if he or she becomes incompetent. The directive provides four paradigmatic scenarios that outline the level of care that is to be provided for varying levels of prognosis and disability of incompetent patients. A proxy can optionally be designated to make decisions for when the patient's preferences are uncertain. The directive also has a section which, for those who desire it, provides for the donation of organs. This legal vehicle provides for a better documentation of the patient's preferences. It is hoped that the Medical Directive will be honored by the courts, as it should facilitate physician-patient discussions of critical and terminal care options.

Analysis, Medical care

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