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.     

Use of advance directives: facilitating health care decisions by adults with mental retardation and their families

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.     

Effect of long-term hyperosmolality on the Na+/H+ exchanger isoform NHE-3 in LLC-PK1 cells

Communication is an important cornerstone to the physician-patient relationship when considering advance directives. Discussing advance directives with patients is a process best initiated in routine, well-adult care that can be made more daunting when the patient is critically ill; yet, when patients are afflicted with cancer, communication on advance directives can be optimized when the primary care physician and oncologist together work with the patient. The need to counsel patients on advance directives regardless of the venue (whether inpatient or outpatient) highlights that an ongoing alliance between the oncologist and the primary care physician can help facilitate consent to, and allow periodic review of, advance directives by cancer patients. This process ensures that the patient's preferences are respected at life's end.     

Strategies to promote the use of advance directives in a residency outpatient practice

OBJECTIVE: To evaluate patient education and resident education strategies to promote advance directives in the outpatient setting, and to assess barriers to implementation. DESIGN: Controlled clinical trial. SETTING: The internal medicine residents' practice of an urban, university medical center. PATIENTS/PARTICIPANTS: Medical residents and 250 patients seen at least twice in the 3 months prior to the study. INTERVENTIONS: We randomized practice days: one to patient education, one to resident education, and three controls. Resident education consisted of a lecture, a videotape of a model advance directives discussion, and videotaping of an actual discussion by each resident, followed by individual review. Patient education consisted of distributing pamphlets in the waiting room and offering all patients an opportunity to discuss advance directives. MEASUREMENTS AND MAIN RESULTS: We interviewed 187 of these patients (response rate 75%) and surveyed 62 residents (response rate 70%). After 18 months, there were no significant differences in the number of advance directives in charts among the three groups. Documented advance directives discussions with patients in the resident education group increased from 3% to 17% (p < .001), more than those in the patient education (5%) or control group (10%, p = .04). Residents in the resident education group were more likely to report discussing advance directives than those in the patient education or control groups (p = .05). Lack of time (95%) and lack of continuity (76%) were the most frequently cited barriers. In multivariate logistic regression, nonwhite race and non-U.S. birth were negatively associated with patient interest in advance directives. Patient race and birthplace were not associated with actual discussions of advance directives. CONCLUSIONS: Even with intensive efforts to educate outpatients and residents about advance directives, important barriers remain, raising questions about how best to promote advance directives among outpatients.     

Completing advance directives for health care decisions: Getting to yes.

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)     

Structure of hypnotic test suggestions and attributions of responding involuntarily.

48 hypnotic and task-motivated undergraduates were administered 3 suggestions and 3 directives in counterbalanced order. The directives instructed Ss to make a series of motor responses while the suggestions implied that the same responses occurred involuntarily. Ss displayed greater overt response to directives than suggestions but rated their responses to suggestions as more involuntary than responses to directives. Suggested responses associated with incongruent proprioceptive feedback were rated as less involuntary than responses associated with congruent feedback. Goal-directed fantasy (GDF) was elicited more frequently by suggestions than directives, and GDF correlated with rated involuntariness and hypnotic susceptibility. Findings are consistent with the notions that hypnotic responding is strategic action moderated by Ss' construal of the test situation and that ratings of involuntariness reflect a socially cued interpretation of experience. (22 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Religious advance directives: the convergence of law, religion, medicine, and public health

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.     

Effect of paradoxical and nonparadoxical self-disclosure on counselor social influence.

Examined the effects of counselor self-disclosure and paradoxical homework directives on Ss' ratings on a 5-item homework directive rating scale and on perceived counselor social influence. It was hypothesized that counselor self-disclosure would reduce potentially negative perceptions of paradoxical directives. 49 female and 40 male undergraduates experiencing problems with test anxiety rated 1 of 4 videotapes of actual counselor–client interaction when a female counselor interviewed a client reporting problems with test anxiety. Results show that paradoxical homework directives were perceived as more tricky, manipulative, and confusing than were nonparadoxical directives but that these perceptions did not affect Ss' perceptions of the counselor's willingness or ability to help or increase feelings of anger toward the counselor. Results also indicate that paradoxical directives were not damaging to perceptions of counselor social influence and the counselor self-disclosure did not affect perceptions of counselor social influence. (17 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Personhood, patienthood, and clinical practice: Reassessing advance directives.

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)     

Physician reluctance to discuss advance directives. An empiric investigation of potential barriers

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.     

The impact of paradoxical interventions on perceptions of the therapist and ratings of treatment acceptability.

Addressed ethical questions about the manipulative, deceptive nature of paradoxical interventions. Perceptions of the therapist and of the acceptability of paradoxical vs nonparadoxical directives were examined using simulation methodology. Participants (97 undergraduates) took part in a semester-long family simulation of excessive family arguing associated with a rebellious adolescent daughter. Before experimental manipulation, the "families" participated in 4 role-playing exercises and attended a family therapy session. They then received a letter from their therapist containing 1 of the 2 types of directives and, subsequently, responded to the dependent measures. Results indicated (1) paradoxical directives did not negatively influence perceptions of therapist attractiveness, expertness, or trustworthiness; (2) they were judged less acceptable than nonparadoxical directives, although neither was deemed unacceptable. Implications for clinical practice and future research are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

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)     

Putting Ifs to Work: Goal-Based Relevance in Conditional Directives.

Conditional directives are used by speakers to instruct hearers which actions are to be taken should certain events occur. The authors demonstrate that conditional directives are distinct from indicative conditionals in which speakers predict what is likely to be observed should certain events occur. The 1st set of experiments shows that goal structure determines what information speakers will select to test whether conditional directives have been followed but that these selections do not reflect their interpretations of the deontic necessity and sufficiency of the conditional relation. The 2nd set of experiments shows that formulations of conditional directives differ in how clearly speakers consider them to express their situation-specific intentions and that hearers accurately perceive what speakers intend them to do as a result of these formulations. The authors' findings illustrate a form of social rationality common in everyday interaction, which broadens normative conceptions of conditionals. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Patients' attitudes toward advance directives and end-of-life treatment decisions

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.     

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)     

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)     

Eyeball position in Graves orbitopathy and its significance for eyelid surgery

OBJECTIVES: This study was designed to identify and compare the attitudes of patients and health care professionals towards advance directives. Advance directives promote recognition of the patient's autonomy, letting the individual exercise a certain measure of control over life-sustaining care and treatment in the eventuality of becoming incompetent. DESIGN: Attitudes to advance directives were evaluated using a 44-item self-reported questionnaire. It yields an overall score as well as five factor scores: autonomy, beneficence, justice, external norms, and the affective dimension. SETTING: Health care institutions in the province of Québec, Canada. Survey sample: The sampling consisted of 921 subjects: 123 patients, 167 physicians, 340 nurses and 291 administrators of health care institutions. RESULTS: Although the general attitude of each population was favourable to the expression of autonomy, multivariate analysis of variance (MANOVA) indicated that physicians attached less importance to this subscale than did other populations (p < .001). Above all, they favoured legal external norms and beneficence. Physicians and administrators also attached less importance to the affective dimension than did patients and nurses. Specifically, physicians' attitudes towards advance directives were shown to be less positive than patients' attitudes. CONCLUSION: More attention should be given to the importance of adequately informing patients about advance directives because they may not represent an adequate means for patients to assert their autonomy.     

A comparison of paradoxical and nonparadoxical interpretations and directives.

Explored the effects of consistent and inconsistent combinations of paradoxical and nonparadoxical interpretations and directives in brief counseling with 49 moderately depressed undergraduates. It was hypothesized that a consistent paradoxical intervention would be more effective than inconsistent interventions, which in turn would be more effective than a consistent nonparadoxical intervention. Ss who wanted to change were randomly assigned to 4 interview intervention conditions and a no-treatment control condition. In the intervention conditions, Ss received 2 interviews with counselors who gave 6 interpretations and 2 directives over the course of the interviews. Ss in the intervention conditions decreased their depression more than did Ss in the control condition. Paradoxical interpretations were associated with more symptom remission than were nonparadoxical interpretations, whereas the nature of the directives students received made little difference. Whether the interventions were consistent or inconsistent made little difference on changes in depression, but Ss had more favorable impressions of their counselors when interpretations and directives were consistent. The impact of the interventions on Ss' attributions of the cause of therapeutic change was also explored. (12 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

General practice of advance directives in the USA

Definition of the problem: Advance directives are written documents which tell what a person wants or does not want if he/she in the future cannot make his/her wishes known about medical treatment. There are three major forms of advance directives in the US: living will, durable power of attorney, and medical directive. Even though advance directives have been used for over 25 years, probably no more than 20% of Americans have prepared a written directive. What are the reasons for this relatively small percentage? It has been argued that they run the opposing risks of either being too general or too specific and that they often use a vague and confusing terminology. Furthermore, the two most frequently cited barriers were the patient's expectation that the physician should take the initiative and the sense that such issues were only relevant for those who were older or in worse health. Progress in developing useful advance directives cannot stop with existing documents. A critical evaluation of advance directives and the development of new ideas will be necessary. Therein, the most important area for future efforts is empirical research.