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1.
OBJECTIVE: We studied whether a simple educational intervention would increase patient completion of advance directives and discussions on end-of-life issues. DESIGN: Randomized, controlled trial. SETTING: Outpatient clinic of a teaching hospital. SUBJECTS: One hundred eighty-seven outpatients of a primary care internal medicine clinic. INTERVENTION: Study subjects attended a 1-hour interactive seminar and received an informational pamphlet and advance directive forms. Control subjects received by mail the pamphlet and forms only. MEASUREMENTS AND MAIN RESULTS: Completion of the advance directive was the main measurement. There were no significant differences in baseline characteristics of either group. Follow-up at 1 month revealed advance directive completion in 38% of study versus 24% of control subjects (p = .04), and discussions on advance planning in 73% of study versus 57% of control subjects (p = .02). Patients most likely to complete the documents were white, married, or attendees at the educational seminar. CONCLUSIONS: Interactive group seminars for medical outpatients increased discussions and use of written advance directives.  相似文献   

2.
Advance directives have been criticized as impractical and/or ineffective, but very little of the criticism differentiates among diverse types of advance directives. The thesis of this article is that carefully drawn documents can be effective. The inadequacy of the advance directive mechanism to date flows in part from documents that are too vague and uninformative. People preparing advance directives are usually seeking to define a level of intolerable indignity at which death becomes preferable. By focusing on the elements of indignity that commonly trouble dying persons, drafters of advance directives can prepare forms that are relevant and meaningful to most people. The author examines the efforts of some existing forms to define intolerable indignity and suggests a different approach. That approach is a unique values profile geared to helping people describe what is, for them, an intolerably deteriorated status. (PsycINFO Database Record (c) 2011 APA, all rights reserved)  相似文献   

3.
Much of the patient education about advance directives described in the literature involves explaining the purpose of advance directives to patients and guiding them through the process of issuing a directive. However, well over half of the subjects in this study claimed to know enough about the directives to issue one, and almost all subjects expressed a preference for issuing directives when healthy. Although health care agencies that wish to adhere to the PSDA must continue to ask all patients if they have issued an advance directive, aggressive patient education programs that press hospitalized patients to consider issuing an advance directive may be perceived by patients as coercive and uncaring. Patient education may be more likely to achieve the goals of the PSDA if it is provided before hospitalization and if patients are encouraged to discuss their care preferences with family members who would be in a position to speak for them at the end of life. Further study of the few patients who choose to issue an advance directive would be informative. When and why they chose to issue the directive should be explored. Patients who report issuing an advance directive but do not provide their physician or hospital with a copy of the directive upon admission should also be studied to determine if this represents a desire not to activate the directive during the current admission or simply confusion about the disposition of this document. Finally, most studies of advance directives have been cross-sectional. Longitudinal study of patients who issue advance directives are needed to determine the effectiveness of these documents in influencing the end-of-life treatment that patients receive.  相似文献   

4.
5.
BACKGROUND: Advance directives are an important part of end of life care, but current advance directive documents do not address the specific issues facing cancer patients. The authors' purpose was: 1) to develop a cancer specific advance directive, 2) determine whether oncology outpatients find this directive more acceptable than a generic advance directive, and 3) describe oncology outpatient preferences for life-sustaining treatment. METHODS: A cancer specific advance directive ("The Cancer Living Will"; the full text of the updated version is available at the University of Toronto Joint Centre for Bioethics website [URL: www.utoronto.ca/jcb]) was developed in four steps: 1) literature search, 2) key informant interviews, 3) focus groups, and 4) evaluation of face and content validity. Subsequently, 91 volunteer oncology patients were given copies of the cancer specific advance directive and the generic advance directive ("The University of Toronto Centre for Bioethics Living Will") from which it was adapted. Acceptability of the advance directive was measured by determining the participants' preferred directive. Participants recorded their treatment preferences in both the cancer specific and generic advance directives. RESULTS: Of 60 patients who returned their questionnaires, 50 expressed a preference for the advance directive. Thirty-two patients (64%; 95% confidence interval (CI), 49-77%) preferred the disease specific Cancer Living Will and 18 patients (36%; 95% CI, 23-51%) preferred the generic Centre for Bioethics Living Will. Most participants who preferred the Cancer Living Will did so because it was more specific and relevant to their situation. CONCLUSIONS: The authors have developed and evaluated a cancer specific advance directive that they believe can be recommended for clinical use with cancer patients.  相似文献   

6.
The Patient Self-Determination Act of 1990 guarantees the right to refuse medical or surgical treatment and the right to draft advance directives. This review of the current literature provides those in nursing staff development and inservice education with an overview of advance directives and their implications for nursing education and practice. Possible core subjects for inclusion in planned, purposeful, advance directive education programs are examined, including cultural sensitivity, facilitator skills, interviewing techniques, legal information, patient autonomy, and reasoning and decision making. This review provides a platform for future research.  相似文献   

7.
This article considers 2 major critiques of advance directives and offers a defense to each of them. The lst critique is philosophical in nature and maintains that the moral authority of an advance directive is undercut by a failure of personal identity to survive the loss of decisional capacity. The response in this article is that this critique relies on a flawed and disfavored concept of persons and their persistence over time. The 2nd critique, pragmatic in nature, argues that advance directives cannot be authoritative because the requisite elements of an informed consent to or refusal of treatment are rarely present, and many such instruments are ambiguous. The author argues that if the creation of advance directives, as a form of advance care planning, is made an integral aspect of clinical practice, many more patients will elect to execute directives, and those directives will not be ambiguous. (PsycINFO Database Record (c) 2011 APA, all rights reserved)  相似文献   

8.
State statutes enabling individuals to draft written durable advance directives for health care have approached future decisions about mental health care and treatment in several quite different ways. While some states incorporate mental health care into the generic advance directive law, others exclude some kinds of mental health care from the generic law, and a growing number of states have established distinct processes for mental health directives. The author surveys the state statutes and examines the extent to which the statutes may create barriers to the use of advance directives by people with mental illness. (PsycINFO Database Record (c) 2011 APA, all rights reserved)  相似文献   

9.
OBJECTIVE: To assess the relationship between ethnicity and Health Care wishes, including Advance Directives, in a group of frail older persons in PACE (Program For All Inclusive Care Of The Elderly). DESIGN: Retrospective chart review of 1193 participants in the PACE program. SETTING: Program of All Inclusive Care Of The Elderly (PACE), a comprehensive managed care demonstration program serving frail older participants at 10 sites across the nation. PARTICIPANTS: A total of 1193 older adults, all of whom met state criteria for nursing home level of care. There were 385 non-Hispanic whites, 364 blacks, 156 Hispanics, and 288 Asians. MEASUREMENTS: Presence or absence of advance directives, type of health care wishes selected including living will, durable power of attorney, and health care proxy. RESULTS: Frail older white, black, Hispanic and Asian Americans differ significantly in their health care wishes and how they choose to express them. Blacks were significantly more likely to select aggressive interventions and less likely than non-Hispanic whites and Hispanics to utilize a written instrument for expressing health care wishes. Whites were significantly more likely to utilize written documents for advance directives, whereas Asians were more likely to select less aggressive interventions but were unlikely to use written advance directives. CONCLUSIONS: In this population, we found significant ethnic variations in choice of health care wishes. Although health care wishes are an individual decision, an awareness of cross cultural patterns can assist practitioners in addressing the concerns of their patients, as well as assisting Health Care Policy Development.  相似文献   

10.
OBJECTIVE: To determine the role of advance directives in decisions to withdraw chronic dialysis in the United States, Germany, and Japan. DESIGN: Survey by questionnaire. PARTICIPANTS: Seventy-two American, 87 German, and 73 Japanese nephrologists. MAIN OUTCOME MEASURES: Each nephrologist's total number of (1) dialysis patients, (2) cases of withdrawal of dialysis, (3) patients with advance directives, and (4) uses of such directives. Nephrologists also stated whether they would continue or stop dialysis in 8 hypothetical cases. RESULTS: American, German, and Japanese nephrologists reported withdrawing dialysis for 5.1%, 1.6%, and 0.7% of their patients in the last year, respectively. Thirty percent of American patients had advance directives, and such directives were used in decision making for 3.2% of all patients. Only 0.3% of German and Japanese patients had advance directives, and such directives were used in decision making for 0.09% of patients. When asked about a hypothetical mentally incompetent patient whose family requests withdrawal of dialysis, American nephrologists were much more likely to stop dialysis in the absence of an advance directive than German or Japanese nephrologists. However, almost all nephrologists from the 3 countries would stop dialysis when a family request to withdraw was supported by a patient advance directive. CONCLUSIONS: There is a high prevalence of advance directives among American dialysis patients, and such directives frequently play a role in decision making. German and Japanese nephrologists appear willing to follow advance directives, but the low prevalence of such directives limits the frequency of their use.  相似文献   

11.
The concept of advance directives for health care decision making has been judicially condoned, legislatively promoted, and systematically implemented by health care institutions, yet the execution rate of advance directives remains low. Physicians should discuss with their patients advance care planning generally and end-of-life issues specifically, preferably when patients are in good health and not when they face an acute medical crisis. The physician–hospital relationship poses particular challenges for the optimal implementation of advance directives that must be addressed. Hospital administrators must improve education of patients and physicians on the value of such documents as well as internal mechanisms to ensure better implementation of directives. Health insurance plans may be better able to ensure optimal gathering and implementation of directives. Patients must become more familiar and more comfortable with advance care planning and the reality of death and dying issues. Full acceptance of the value of directives ultimately rests on achieving full participation of all involved—providers, patients, families, and payors—in this most profound process. (PsycINFO Database Record (c) 2011 APA, all rights reserved)  相似文献   

12.
BACKGROUND: This study examines the use of advance directives, limitations of treatment, and medical interventions during the terminal hospitalization of the old-old. Study periods before and after the implementation of the Patient Self-Determination Act of 1990 were chosen to determine if there has been a change in terminal care. METHODS: Chart review was performed for all patients 85 years and older who died in the hospital during 1988 and 1993. Patient characteristics, presence of advance directives, do-not-resuscitate orders, and other treatment limitations were noted as were interventions listed in the Medical Directive. RESULTS: Less than 12% of the 167 study patients had an advance directive. Length of stay for these terminal admissions decreased from 18.5 to 9.6 days. Ninety-five percent of the patients were "do not resuscitate" by time of death, but orders were written sooner in 1993--75% within 24 hours of admission. Patients with early do-not-resuscitate orders had fewer high-intensity interventions. More patients had "comfort measures only" during the study period. An overall decrease in high-intensity interventions and a specific decrease in the use of transfusions, invasive tests, minor surgery, and cardiopulmonary resuscitation was seen. CONCLUSION: Patients 85 years and older are receiving fewer high-intensity interventions during their terminal hospitalizations. More attention is being paid to comfort and few are receiving cardiopulmonary resuscitation. There is little reference to formal advance directives in decision making for these patients.  相似文献   

13.
Medical advance directives for end-of-life decisions at times that patients cannot express their preferences have become a major trend in recent state and federal legislation. The author argues that an extension of directives to cover future psychiatric treatment are fraught with both practical and ethical dilemmas. Although the potential for increasing patient autonomy is certainly positive, the potential for implementing covert ideological agendas has been present from the beginning, and the significant differences between medical end-of-life decisions and ongoing treatment of psychiatric patients must weigh against psychiatric advance directives unless major changes are made in existing procedures. (PsycINFO Database Record (c) 2011 APA, all rights reserved)  相似文献   

14.
BACKGROUND: With the passage of the Patient Self-Determination Act in 1990, new procedures and documents became available for planning end-of-life care. These new procedures and documents are now being examined scientifically. OBJECTIVE: To review existing research on the use of advance directives. DATA SOURCES: Computer search using Grateful Med software from the National Library of Medicine with MEDLINE and BIOETHICSLINE databases. STUDY SELECTION: Studies that showed an emerging consensus or reported vastly differing results were selected. Selected studies examined these specific areas: demographic data on patients with advance directives, completion rates, capacity to complete, patients' preferences, stability of patients' decisions over time, treatment choices, proxy decision makers, treatment provided, and cost. RESULTS: The body of important research about advance directives is growing. A profile of their clinical utility is emerging. CONCLUSIONS: The research done so far can stimulate future research and can begin to suggest possible changes in practice. However, the body of research is not yet large enough or well controlled enough to answer conclusively many of the questions about planning of end-of-life care.  相似文献   

15.
BACKGROUND: To determine the relative impact of five proposed barriers to physician usage of advance directives with the aim of increasing the number of advance directives generated. METHODS: Questionnaires were sent to 460 internal medicine resident and attending physicians at a large New York, NY, hospital. Of these, 277 (60%) responded. We used multiple regression to measure the impact of five barriers to physician-initiated discussions of advance directives (time constraints, compensation concerns, discomfort with the subject, beliefs about appropriateness, and lack of understanding) on respondents' estimates of the number of advance directives held by respondents' patients, the number of recent advance directive discussions, and the number of discussions initiated by physicians. RESULTS: Physician lack of understanding and erroneous beliefs about appropriateness had particularly strong effects, serving as barriers to recent advance directive discussions (P < .0001 and P < .0001, respectively) and total number of advance directives held (P < .0001 and P < .02). Physicians' lack of knowledge also served as a barrier to the percentage of discussions that were physician initiated (P < .003 and P < .04). Time constraints and lack of comfort affected only discussions that were physician initiated (P < .001). Compensation concerns did not appear to serve as a barrier. Respondents were supportive of the concept of advance directives but reported minimal use of them in appropriate situations. CONCLUSIONS: Attention can now be focused on methods to overcome the five barriers studied and thereby enhance the execution of advance directives.  相似文献   

16.
An important reason why advance directive instruments are underused is that people faced with the need to think about the end of life, future mental health problems, or the need for nursing home admission experience psychological stress that produces denial and procrastination. This essay examines how lawyers who are counseling clients about advance directive instruments can deal with such client denial and resistance. It explains the psychological defense mechanism of denial and related forms of resistance and offers suggestions about techniques that lawyers can use for dealing with denial and resistance in counseling clients about advance directives. It suggests ways in which lawyers can develop their interpersonal skills, becoming more empathic and more sensitive to their clients' psychological needs. (PsycINFO Database Record (c) 2011 APA, all rights reserved)  相似文献   

17.
The use of instructional advance directives assumes that preferences for life-sustaining medical treatment remain stable over time and across changes in life condition. A sample of 332 older adults recorded their preferences for 4 life-sustaining treatments in 9 illness scenarios. These preferences were elicited again 1 and 2 years after the original interview. Overall, preferences for life-sustaining treatment were moderately stable over time, but stability varied significantly across judgments. Preferences were most stable for illness scenarios that were most and least serious and for decisions to refuse treatment. Age, gender, education, and prior completion of an advance directive were all related to preference stability, and evidence indicated that declines in physical or psychological functioning resulted in decreased interest in life-sustaining treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)  相似文献   

18.
As increasing numbers of adults with mental retardation survive into adulthood and old age, they may face decisions about their health care and end-of-life treatment. Advance directives may serve as a tool for communicating one's preferences about future medical treatment. Information about the types, extent of use, and ethical context of advanced directives is provided and four critical issues regarding use of advanced directives by adults with mental retardation and their families are examined: assessment of decision-making capacity, standards for surrogate decision-making, family involvement in advanced directives planning, and constraints on the use of advanced directives. Implications for professionals are discussed, including ways to facilitate advance care planning.  相似文献   

19.
The purpose of our survey was to investigate the experience of physicians regarding advance directives and other medical decisions concerning the end of life. A postal questionnaire was sent to 500 Japanese physicians who were most involved in medical care of terminal patients. A total of 339 (68%) physicians responded. In dealing with terminal patients, approximately half gave priority to their patients' wishes for medical care, if known, regardless of the patient's competency. Of the respondents, 149 had been presented with advance directives by their patients and 35% followed all advance directives presented in their practice. Cardiopulmonary resuscitation (CPR) for arrested patients to enable their family to be at the bedside at the time of the death was common. More than 60% of the respondents thought that active euthanasia and assisted suicide were never ethically justified. Our study indicates that the wishes of patients are currently not always given top priority in medical decisions concerning the end of life.  相似文献   

20.
Because of the deep interpersonal significance of decisions made at the end of life, it is not surprising that religion has played an important role in patient and family decision making. Specific religious concerns about death and dying have led to religious advance directives. Advance directives offer a case study of models of interaction between religious communities and secular institutions. This paper examines why such directives have been created and how they may affect health care decisions. An analysis of their strengths and weaknesses concludes that specific religious instructions are unnecessary in written directives and may undermine both the religious and health care goals of patients.  相似文献   

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