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)     

Optimal use of orders not to intervene and advance directives.

More rigorous efforts in advance care planning are required in order to tailor end-of-life care to the preferences of patients so that they can experience a satisfactory last chapter of their lives. There is need for better availability and tracking of advance directives, and more uniform adoption of form documents that can be honored in every state. The discouraging evidence of inadequate end-of-life decision making indicates the necessity of several improvement strategies. In response to this need, the Council on Ethical and Judicial Affairs of the American Medical Association has examined this issue again and presents the following report and recommendations. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

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)     

Multicultural considerations in the use of advance directives

Capillary zone electrophoresis with indirect UV-detection was used to separate mixtures containing both positively and negatively charged species. In order to understand the dependence of detector response patterns on the changes in compositions of the background electrolytes and the charge of marker ions (UV-absorbing ions), the separations were performed in two different systems. In a three-ion system (analyte ion, coion and counterion) a marker ion was the major ionic component of a buffer solution and in a two-coion or counterion system the marker ion was used as an additive. In the three-ion system the response profile of an analyte was in good agreement with the mathematical treatment based on the Kohlrausch regulation function. In the two-coion or counterion system the response patterns were more complicated; however, the experimental results agree well with data obtained from a computer simulation program. Peak directions of the analytes were not only determined by their relative charge to the marker ion, but were also associated with their relative mobilities to the buffer coion and the marker ion. The analytes with higher effective mobilities compared to the marker ion were detected as positive peaks and the ones with lower effective mobilities as negative peaks. Similarly to the three-ion system, the detector response of an analyte was stronger by applying a marker coion compared to a counterion. An interesting result was obtained in the separation of a mixture of quaternary ammonium ions and sugars by using a cationic marker ion. The highest and most symmetrical peak was not a cation, but raffinose anion, which appeared most closely to the system peak. The observation suggests that the electromigration dispersion in its zone was eliminated by migrating close to the electroosmosis. A system peak with the mobility corresponding to the electroosmotic flow was obtained in both systems, and an additional system peak with a mobility close to that the marker ion was present in the systems using marker ions as additives.     

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.     

Increasing the use of advance directives in medical outpatients

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.     

Assessment of capacity to discuss advance care planning in nursing homes

Sphingolipidoses are human metabolic storage disorders characterized by the accumulation of harmful quantities of glycosphingolipids and phosphosphingolipids. These lipids have in common a hydrophobic portion of their structure called ceramide. In glycosphingolipids, various oligosaccharides are linked to ceramide through glycosidic bonds. An example is glucocerebroside, composed of ceramide and 1 molecule of glucose. Large quantities of glucocerebroside accumulate in tissues in patients with Gaucher disease. Higher oligosaccharide homologues contain additional neutral and acidic oligosaccharides. Among these are gangliosides that have 1 or more molecules of N-acetylneuraminic acid. A ganglioside called G(M2) accumulates in Tay-Sachs disease. Sphingomyelin is a phosphosphingolipid that accumulates in patients with Niemann-Pick disease.     

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)     

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.     

An event-related potential investigation of posthypnotic recognition amnesia.

Forty-two individuals selected for high hypnotizability or for low hypnotizability were taught lists of words during hypnosis and assessed for recognition following hypnosis using event-related potential (ERP) procedures, both before and after the cue to reverse amnesia. A subgroup of low-hypnotizable participants were asked to simulate hypnotic behavior. All participants had larger late positive component (LPC) amplitudes to learned than to unlearned words, regardless of whether amnesia was reported. The highly hypnotizable participants who reported recognition amnesia, however, had significant changes in attention-related (P1 and N1) and recognition-related (N400 and LPC) ERP component amplitudes as a function of whether amnesia was reported. These data suggest that posthypnotic amnesia may involve alterations in the processes of attention, selection, and accessibility. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Durable powers of attorney as a substitute for conservatorship: Lessons for advance directives.

The author traces the evolution of the use of durable powers of attorney and reviews problems of guardianship, the guardianship reform movement, and the advent of durable powers of attorney as a response. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Physician management preferences and barriers to care for rural patients with depression

OBJECTIVE: To describe rural primary care physicians' current preferences in treating depression and the barriers they face in providing effective care for this condition. DESIGN: Cross-sectional survey of randomly selected practicing primary care physicians registered in Arkansas. SETTING: Primary care practices in nonmetropolitan counties. PARTICIPANTS: Forty of 50 eligible physicians completed a face-to-face interview; one physician, an interview by telephone; and two physicians, an interview in questionnaire form. Total response rate was 86%. MAIN OUTCOME MEASURES: Physician preferences for and barriers to the effective management of depression. RESULTS: An estimated 44% of rural physicians consider medication alone to be the best initial approach to treating depression; 30% prefer to prescribe medication and refer patients to mental health care professionals for counseling; and 26% prefer to prescribe medication and conduct counseling themselves. The greatest barriers to treatment were the physician's lack of time and the patient's failure to recognize depression. Most physicians had recently referred one or more depressed patients to specialty care and had encountered few referral sources, long waiting lists, and inadequate follow-up. CONCLUSIONS: The majority of rural primary care physicians prefer to treat depressed patients in their practices themselves. Except for the limited availability of specialty services, most of the barriers to the provision of effective care for depression perceived by rural physicians do not appear to be unique to rural practices.     

Parent-adolescent communication about sexual intercourse: An analysis of maternal reluctance to communicate.

Objective: A unified theory of behavior was applied to parent-adolescent communication about sexual intercourse to understand why some mothers speak less often with their children about not having sexual intercourse. According to the theory, parental decisions or intentions to engage in such conversations are a function of expectancies, social norms, self-concept, emotions, and self-efficacy. Design: Data were collected from a random sample of 668 mother-adolescent dyads recruited from middle schools located in the Bronx community of New York City. Data were collected via self-administered surveys. Main Outcome Measures: Mother and adolescent reports on the frequency of parent-adolescent communication about sexual intercourse were obtained. Adolescents and mothers reported how often the mother had discussed 21 topics related to sexual behavior. Results and Conclusion: Results supported the utility of the framework for understanding parent-adolescent communication about sexual intercourse. Significant maternal correlates included (a) expectancies about lacking knowledge, being embarrassed and encouraging children to think maturely and focus on school; (b) self-concept and perceiving that mothers who didn't talk with their children about sex were irresponsible; (c) emotions about feeling relaxed and comfortable; and (d) self-efficacy about the ease of talking with one's child. Implications for family based prevention programs are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)