Advance directives.

There is significant confusion about the topic of advance directives (ADs), stimulated by the increasing realization that current AD instruments probably have little salutary clinical effect. The instruments themselves are almost certainly part of the problem. In most cases they are too simple and narrowly focused, and one, the Medical Directive, is pointlessly complex. Seven suggestions are proposed for creating more adequate AD forms. The American Medical Association's recent report on ADs is disappointingly superficial and does not usefully diagnose or suggest solutions for the problems in this area of clinical practice. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Advance thinking about advance directives

Stilboestrol tablets (20 x 1 mg) were given to 4 ostriches. Urine was collected over a period of 8 days and stored frozen at-20 degrees C pending analysis. Analyses were performed on a gas chromatograph-mass selective detector for the presence of parent compound and/or metabolites. Diethylstilbestrol and its metabolite, dienestrol, were detected in urine; dienestrol only for 1 day but diethylstilbestrol for 8 days after administration. Residue analysis for the use of diethylstilbestrol as growth promoter can be performed on the urine of ostriches by scanning for parent compound only since it can be detected longer than the metabolite.     

Advance directives and advocacy in end-of-life decisions

This article examines the issue of advocacy for all adults in end-of-life decisions to help enhance the role of health care providers as partners in decision making. The ethical issues of death and dying are of particular concern for the elderly. Conflicts may prevent providers and nurses from creating a good dying experience for patients and family. Among the many issues associated with end-of-life decision making are futility, autonomy, and quality of life, a "good death," advance directives, family distress, and the culture of medicine. To overcome related barriers, involved health care providers can promote advocacy by offering choices in end-of-life care and providing an environment of listening and communication. Initiating and maintaining dialogue on this difficult subject will provide better care to patients and families.     

Development and validation of a multidimensional multivariate model for accounting for infractions in a correctional setting.

A Person by Situation by Response Mode by Reinforcer (sanction) model for accounting for infractions of rules by male inmates incarcerated in a federal correctional facility was developed and evaluated. In a series of 4 preliminary studies, a 720 (number of inmates) by 16 (number of institutional subsettings in which infractions occurred) by 63 (number of types of infractions defined by institutional authorities) by 30 (number of existing sanctions contingent on institutional infractions) model was empirically refined into a 3 by 2 by 4 by 2 model. The utility of the model was assessed using questionnaire and ex post facto methodology. Second- and 3rd-order interactions were inconsequential in accounting for behavioral variance. Findings that were replicated across studies (response mode main effect, Person by Sanction interaction) indicate that management policies should be designed such that incarceration in institutions is less conducive to verbal aggression and evasion and that institutional disciplinary procedures should be matched to inmate types. (55 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Advance directives: the price of life

Advance directives support the concepts of patient autonomy and resource allocation. Promotion of advance directives by nurse managers according to the suggested paradigm should be an economic and policy priority.     

Advance directives: role of nurse practitioners

Systematical screening by cytological cervix examination has not reduced the mortality from cervical carcinoma as much as was expected. One important cause of this is the varying sensitivity of the screening owing to the large number of smears, most of which are normal. Some improvement of the effect of screening might be achieved by combination with computer-assisted microscopical evaluation and with testing for human papilloma virus (PV).     

Advance directives: the emerging body of research

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.     

Advance directives for psychiatric treatment: A view from the trenches.

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)     

Issues in prison hospice: toward a model for the delivery of hospice care in a correctional setting

This paper examines issues in prison hospice care based on the author's nine years experience as a prison hospice worker and trainer and on data gathered by the National Prison Hospice Association (NPHA) from a number of federal and state prison medical facilities with operational or developing hospice programs, including both scatter-bed and hospice unit models, employing inmate hospice volunteers and the services of outside community hospice agencies and volunteers. The paper discusses DNR orders and curative vs. palliative care decisions, pain management, AIDS care, interdisciplinary care teams, staff and volunteer training and supervision, and the need for compassionate early release and community placement programs. The author proposes a set of preliminary guidelines for the delivery of hospice care in the correctional setting.     

Advance directives for mental health care: An analysis of state statutes.

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)     

New approaches to syphilis control. Finding opportunities for syphilis treatment and congenital syphilis prevention in a women's correctional setting

BACKGROUND: With prostitution and drugs the most common reasons for arrest among New York City (NYC) women, female arrestees are at high risk for acquiring syphilis and delivering congenitally infected babies. Despite routine syphilis screening of all NYC inmates, many are released before the need for treatment is recognized, and once released, few could be found for treatment. GOALS: To improve syphilis treatment rates among female correctional inmates in NYC. STUDY DESIGN: At a women's correctional health clinic, on-site, rapid, qualitative nontreponemal syphilis testing (STAT rapid plasma reagin [RPR]) and on-line access to the local syphilis case registry were introduced to supplement the usual admission medical evaluation. Treatment decisions made using the authors' jail protocol were compared with treatment criteria used in NYC's sexually transmitted disease (STD) clinics. Patients consisted of a consecutive sample of 685 remandees admitted one or more times during the day shift, March 24, 1993, to July 31, 1993, who had a full complement of mandatory admission medical tests. Using the study protocol, syphilis treatment decisions were made and needed treatment was furnished at the end of the admission medical evaluation. The main outcome measures were correct identification and treatment of syphilis in this population, compared with standard NYC Department of Health (DOH) STD clinic practice, as well as the effect of the jail protocol on pregnancy outcomes and need to treat offspring for congenital syphilis. RESULTS: Compared with NYC DOH STD clinic practice, the study protocol was 95% sensitive and 88% specific in arriving at appropriate treatment for syphilis. Treatment at the end of the admission medical evaluation increased syphilis treatment rates from 7% to 84% of women with indications for treatment and to 88% of pregnant women with indications for treatment. Prospective follow-up for birth outcomes revealed no spontaneous abortions and eight live births. Seven of the eight did not need congenital syphilis treatment because their mothers were adequately treated while incarcerated. CONCLUSIONS: Qualitative (or STAT) RPR testing and access to DOH syphilis case registry data provide prompt and accurate diagnostic information that can lead to an overall increase in the number of inmates appropriately treated (with a minimum amoung of overtreatment) in a women's correctional facility. This protocol may be applicable in other high-risk, transient populations.     

Personal reflections on a career in correctional psychology.

Kathleen M. Hawk's training as a psychologist provided excellent preparation for each of her assignments as a career employee of the Federal Bureau of Prisons, from staff psychologist, to warden, to her current position as director. The mission of the prison-based psychologist—to assist in the rehabilitation of offenders and in their reintegration into society—is central to the mission of corrections. Moreover, by helping to promote a healthy prison environment, psychologists can enhance safety for staff and inmates alike. Prison-based psychologists also may be involved in numerous consultative and research activities. There is high demand for psychologists in the nation's prison systems, and they can exercise considerable influence over corrections policies. More psychologists should consider corrections as a career. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Detecting fake-good MMPI-A profiles in a correctional facility.

This study examined the extent to which the validity scales of the Minnesota Multiphasic Personality Inventory-Adolescent (MMPI-A; J. N. Butcher et al., 1992) could differentiate between correctional adolescents instructed to fake good and both correctional and noncorrectional adolescents who received standard instructions. The noncorrectional participants (n?=?137) were from settings not connected with treatment or correctional facilities. Correctional participants (n?=?140) were from a facility in Northeastern Ohio. Mean profiles resembled those previously reported for adults on the MMPI and MMPI-2 and for adolescents on the MMPI and MMPI-A. It was possible to differentiate between (a) correctional youth instructed to fake good and noncorrectional youth with standard instructions and (b) correctional youth who were faking and correctional youth with standard instructions. Slightly different cutoff scores were needed for these two discriminations. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Advance directives for psychiatric care: A theoretical and practical overview for legal professionals.

An advance directive for psychiatric care is a legally enforceable document that specifies the manner in which psychiatric treatment decisions are to be made in the event that a person later becomes incompetent to make informed health care decisions. Although the concept of psychiatric advance directives has gained considerable popularity in recent years, the groundswell of interest in these instruments largely precedes the development of a coherent body of governing law. Existing state statutes and case law provide significant legal authority for the use and enforcement of advance directives in psychiatric settings, but serious questions remain concerning the scope of their enforceability, particularly in the context of involuntary treatment. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

"A place like that": Advance directives and nursing home admissions.

Decisions about admitting a mentally incapacitated person to a nursing home raise a variety of difficult legal, ethical, and public policy issues. A strategy for anticipating and addressing this contingency prospectively, by encouraging execution of formal advance planning directives while the individual is still capable, may mitigate some of the dilemmas associated with these issues. The author discusses the contours and feasibility of such a strategy, analyzing the possible uses of advance directives both for prospectively authorizing nursing home admission on one's own behalf and for refusing such admission, or placing explicit conditions on such admission, in advance of the time that the actual decision must be made. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Advance directives, AIDS, and mental health: TJ preventive law for the HIV-positive client.

Unfortunately, the possibility of future incapacity to engage in health care decision making remains one of the many potential legal problems faced by HIV-positive clients. Consequently, proactive legal planning, including the use of advance directives, is widely recognized as an important element in avoiding legal crisis for HIV-positive persons. The author suggests that, in light of the emotional and psychological difficulties that an HIV-positive client may face, considerations of psychological well-being ought to be explicitly recognized as one priority among many in legal planning. By integrating principles of therapeutic jurisprudence and preventive law, a lawyer can both protect an HIV-positive client's legal rights by planning for legal contingencies and enhance the client's psychological well-being by making emotional concerns one priority in that planning process. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Advance directives and withdrawal of dialysis in the United States, Germany, and Japan

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.     

Advance directives and other medical decisions concerning the end of life in cancer patients in Japan

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.     

Making advance directives meaningful.

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)