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.

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 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.     

Family dynamics in end-of-life treatment decisions

The decision to withhold or withdraw life-sustaining treatment is now regularly weighed in chronic or terminal illness. Families are usually supportive advocates and concerned surrogate decision makers for patients, although they can also counter the wishes of the patient and disagree with the treatment team. Understanding the range of factors--internal and external, confronting the individual members and the family as a whole--that can influence family responses helps in working with families at this critical juncture in an illness. Interventions to assist the family and treatment team are discussed.     

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 in a correctional setting.

Using advance directives to preconsent to mental health treatment is a promising approach to contending with the quandary posed by patients suffering from severe mental health illness, particularly those in a prison setting. The implementation of advance directives represents unfamiliar territory because it focuses on the patient's ability to preconsent to treatment rather than the commonly interpreted prerefusal of treatment. The challenge of consenting in the prison system generates a set of unique problems. The environment in which the instrument is signed can impose significant pressures and therefore result in a viable legal challenge. The prison setting is the most coercive environment in which a patient can be treated, particularly when the patient is mentally ill. Mentally ill prisoners signing preconsent for treatment advance directives have an opportunity for unprecedented relief yet may also experience pressure to select treatments desirable to the prison staff. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

False memories for end-of-life decisions.

Objective: To examine people's false memories for end-of-life decisions. Design: In Study 1, older adults decided which life-sustaining treatments they would want if they were seriously ill. They made these judgments twice, approximately 12 months apart. At Time 2, older adults and their self-selected surrogate decision makers tried to recall the older adults' Time 1 decisions. In Study 2, younger adults made treatment decisions twice, approximately 4 months apart. At Time 2, younger adults tried to recall their Time 1 decisions. Main Outcome Measures: Percentage of participants who falsely remembered that their original treatment decisions were the same as their current decisions. Results: In Study 1, older adults falsely remembered that 75% of their original decisions were the same as their current decisions; surrogates falsely thought that 86% of older adults' decisions were the same. In Study 2, younger adults falsely remembered that 69% of their original decisions were the same as their current decisions. Conclusion: Age alone cannot account for people's false memories of their end-of-life decisions; we discuss other mechanisms. The results have practical implications for policies that encourage people to make legal documents specifying their end-of-life treatment decisions. (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).     

Elders' end-of-life decisions: implications for hospice care

Elders' views on various end-of-life decision options were studied to determine each option's acceptability if they were faced with the need for such decisions. 388 black and white elders aged 60 to 100 responded to 17 decision scenarios depicting situations with a low quality of life, rating acceptability of each of 7 options for each scenario. Based on factor analysis of responses over scenarios, three scores were computed: maintaining life, ending life, and letting others decide. Profile types were identified and related to demographic background and personality variables. Implications for hospice care are drawn.     

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.     

Relationship of psychosocial and background variables to older adults' end-of-life decisions.

Aims were to determine acceptability of a full range of end-of-life decision options and identify related variables; 388 Black and White older adults ages 60–100 responded to 17 decision situations depicting terminal and nonterminal conditions with a very low quality of life, rating the acceptability of 7 end-of-life options per decision situation, and completed demographic, health, and psychosocial measures. Despite low quality of life, maintaining life (striving to live and seeking treatment) was the most acceptable option, but a significant minority of participants wished to end life (suicide, assisted suicide, or euthanasia) and a moderate number wished to defer the decision to others. In hierarchical regressions, psychosocial variables (religiosity, values, fear of death, etc.) contributed significantly (p?     

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)     

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 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)     

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)     

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)