Advanced directives and their legal implications

Advanced Directive

The 1991 the Patient Self-Determination Act (PSDA) was designed to give patients and their families greater autonomy over making decisions in regards to end-of-life care and minimizing the extension life beyond what would be considered a 'quality' level. It has been said that "advanced care planning increases the quality of life of dying patients, improves the experience of family members and decreases health care costs" for patients of a variety of backgrounds (Eggertson 2013). However, few patients are aware of how to go about constructing such directives even though the evidence indicates that most have clear preferences about how their end-of-life care should be managed. "A recent study in Maryland found that although 'only 34% of respondents had an AD, 61% indicated that they have preferences about medical care in the event they are unable to make such decisions', and of these '83% said it was very important that their preferences be carried out'" (Brown 2012).

But many patients lack the knowledge and resources to know what types of advanced directive options exist (either constructing a living will or giving someone the legal power to act as a surrogate). They also must understand the need to "keep the advanced directive on hand and on record and present them to medical providers in a timely fashion" (Brown 2012). There are additional concerns that physicians may not be proactive in carrying out advanced directives because of fears of litigation from family members who wish to sustain their loved one's life in defiance of an AD. Nurses can play a valuable role in informing patients of their options while they are still capable of making decisions and also involve the patient's loved ones in a manner so that the patient's directives are clearly expressed and defined.

Having the nurse as a 'third party' to such a discussion can be invaluable given the objectivity the nurse can offer which is simultaneously informed by the compassion of her profession and medical knowledge. Nurses who offer end-of-life counseling should have cultural as well as interpersonal sensitivity to cultural differences which may arise. "End-of-life care may present unique challenges and opportunities in culturally discordant hospitalist-patient relationships. Culturally competent health care in an increasingly diverse population requires awareness of the importance of culture, particularly spirituality/religion and race/ethnicity, in the care of hospitalized patients at the end of life" (Mitchel & Mitchel 2009). For example, Latinos may wish to have extended family members participate in the discussion of end-of-life care of a loved one. "Several studies have documented…that African-Americans prefer more-aggressive treatment at the end of life than do whites and are less likely to have formalized advance directives" (Mitchel & Mitchel 2009). Cultures may have various rituals and traditions regarding how illnesses is viewed and treated that the nurse should be aware of, even if she is offering a Westernized, medical perspective of how to proceed.