Advanced directives in healthcare decision-making

Advanced Directives

Death is a natural and inescapable part of life and people recognize the fact that one day they too shall have to die. Most people wish to die peacefully and with dignity. However, modern medical techniques have helped to keep many people alive through artificial means placing a huge emotional and financial burden on family and friends and robbing the patient of his/her right to die with dignity. ("Advance Medical Directives.," n. d.) This is where "Advance Directives" come in. Advance Directives refer to formal documents or verbal statements which determine how a patient's healthcare decisions will be made in case the patient loses the ability to direct the decisions himself. Advance Directives are of two types -- living wills and health care power of attorney or durable power of attorney. ("Advance Medical Directives.," n. d.); (Feldman; Christensen, 2007)

Through a living will a patient can himself direct what kind of treatment will be acceptable to him in case he loses his ability to make decisions. Living wills come into operation only when patients lose the ability to communicate to others or when the situations specified in the LW document take place. Such situations specified in the living will may include persistent vegetative state, a terminal illness or inability to take independent decisions. Living wills may also specify what kind of treatments should be allowed or not allowed or may simply specify general goals. The specified treatments may include nutrition, artificial ventilation, artificial hydration and CPR. Through a health care power of attorney, patients can designate a proxy or a person who can take decisions on their behalf when they become incapacitated. This kind of advance directives provides more flexibility than living wills since it is not possible to anticipate all kinds of medical conditions and treatment alternatives that a person may undergo or require in the future. Do-not-resuscitate -- DNR advance directives are a sort of advance directives which explicitly specifies the withholding of techniques like defibrillation, artificially supplied respiratory support, specifically closed-chest cardiac message and CPR. ("Advance Medical Directives.," n. d.); (Feldman; Christensen, 2007)

The DNR orders are usually a written order by a patient's physician and depend on the explicit wishes expressed by patients or their families about limiting treatment involving extraordinary measures to keep the patient alive. The DNR status must be an informed consent by a patient or his/her legal representative. The DNR order must be a very clear and unambiguous document and its contents must be clear enough so that the treatment options not specified in the order can be continued. Nurses, doctors or other health care providers can not be a witness to the informed consent for DNR given by a patient. (Billings, 2008)

Most states have specific laws regarding advance directives in a written format which permit any competent adult to prepare a legal document which expresses their wishes about their treatment during future medical conditions. However, the written format's language must stick to the specific laws of the state in which the patient resides. (Sharpe, 1999) Some states permit specific pre-hospital DNR only which can be followed by emergency response personnel. Patients who have DNR orders may wear a necklace, bracelet or some other form of an indicator which points out that they have a DNR order. Many states stipulate that emergency response personnel must verify with the original DNR document despite having an indicator before honoring the DNR order. According to the PSDA or Patient Self-Determination Act of 1990, the control, language and format of any kind of advance directive must be in accordance to an individual state's law. (Sharpe, 1999); (Johnson, 2001)

As per the PSDA, health care institutions must develop procedures and policies that recognize as well as honor the rights of a patient under the purview of state statutes to refuse or accept a particular kind of medical treatment. According to PSDA, health care institutions that receive federal financial aid from organizations like Medicaid or Medicare must inform all patients about their rights specifically in a written form at the time of admission to the hospital. Emergency response personnel should keep in mind that having a DNR order does not mean that treatment should be denied to a patient who has experienced an injury or an illness. A DNR order mainly applies to patients who have had a respiratory or cardiac arrest. In case such a health care provider is faced with an ambiguous situation with regard to advance directives, they must consult medical control for the appropriate actions to be carried out. (Sharpe, 1999); (Johnson, 2001)

A verbal DNR order poses an unwarranted risk to the medical community. Doctors and nurses, therefore, have to take adequate precautions against such a liability and must make it a point to neither accept nor act upon a DNR order given verbally. In case there is no evidence of a doctor-activated advance directive or a no-code order, medical staff must initiate all possible treatment options and work as if the order does not exist at all. In case there is a respiratory or a cardiac arrest even of terminally ill patients, they must start full-code protocols and resuscitation efforts immediately. However, in case there is sufficient evidence that an explicit written advance directive exists, medical staff must not call a code or else they may be exposing themselves to battery charges and doing an injustice to the patient as well. (Sharpe, 1999); (Johnson, 2001) Nurses or physicians who try to resuscitate a patient in a situation where an explicit DNR order is present would be operating without the consent of the patient and may face battery charges. (Billings, 2008)

Basically battery means touching a person unlawfully including initiating emergency care without the consent of the patient. Battery charges are implemented when a patient "who wants nothing done" is provided treatment. (Lippincott Williams & Wilkins, 2004); (American Academy of Orthopaedic Surgeons, 2006) Health care providers who have initiated treatment and have not complied with some specifications of patient-specified advance directives have often been charged with lawsuits and sometimes this has also become a part of a malpractice lawsuit. In such a case, the lay and paralegal reviewer may be challenged in court to explain the propriety of the treatment provided after a scrutiny of the language used in the patient's advance directive and their medical record view is made. (Sharpe, 1999)

It is accepted that a patient has the right to accept or refuse a particular line of treatment and has the right to respectful care. These facts are recognized and specified in the "Patient's Bill of Rights" developed by the American Hospital Association. One of the points in the Bill of Rights is related to advance directives. It mentions that every patient has the right to specify an advance directive regarding the kind of treatment that he/she might accept or refuse in future. It also mentions that a person may be designated as a "surrogate decision maker" to take decisions on the patient's behalf. It is expected that the hospital will abide by the advance directive specifications but only to the extent allowed by hospital policy and state laws. ("Patient Bill of Rights," 2008)

It is also expected that health care institutions will inform their patients about their rights permitted under hospital policy and state law, assist them in making informed medical decisions, enquire from the patient about the existence of any advance directives, and lastly include such information in their medical records. The "Patient's Bill of Rights" also specifies that the patient has the right to obtain timely notification about any such hospital policy that may prevent the hospital from carrying out a legally valid advance directive to the full extent. It must be remembered that the "Patient Bill of Rights" is not a state law but has simply been developed based on the respect, understanding and trust that exists or should exist between a patient and health care professionals and/or institutions. ("Patient Bill of Rights," 2008)

Views about advance directives like DNR varies in patients and their families with many of them getting distressed over this issue and equating DNR with giving up or abandonment of the patient. This may be because of the way health care personnel highlight what treatment will be held back instead of emphasizing on what treatment or care will be provided. Many patients and their families feel that having an advance directive will result in a suboptimal care or second-class treatment. The reason for such a viewpoint may be that the health care institutions or medical personnel with whom they might have interacted with do not have adequate and proper knowledge about the limited focus that a DNR order has. Patients and their families need to be educated that a DNR order does not mean suboptimal care and does not restrict other options of medical treatment. Even if an advance directive stipulates that all types of life-sustaining treatments should be withheld, it is to be expected and also emphasized that comfort care, respect for patient's dignity, and pain control measures is provided. However, it does mean that some things will be different from the normal line of treatment. ("Advance Medical Directives.," n. d.); (Feldman, Mitchell D; Christensen, John F. (2007)

The fact that resuscitation of a patient through CPR will not add significantly to the quantity and quality of life is an indication that death may not be very far off and that medicine does not have the power to turn around the dying process. CPR has not only proved to be ineffective for terminally ill patients but the harsh nature of its functioning make it a technological, cruel and expensive death process. The results of many studies have indicated that the "out-of-hospital survival" rate of patients suffering from multisystem disease like renal failure and advanced cancers have not increased as a result of CPR. Conflicts often crop up when the patient's family members, friends or relatives who have a vested interest in the welfare or estate of the patient can not comprehend the medical, ethical and legal implications of the advance directives specified by the patient. Doctors are likely to be threatened with charges of malpractices by the relatives of patients who insist on compliance, or even noncompliance with those specifications provided in the advance directive which are unacceptable to them. Therefore many state laws have provisions for extending immunity from liability to doctors who make decisions in good faith about life-saving medical procedures initiated in specific situations. ("Advance Medical Directives.," n. d.); (Feldman; Christensen, 2007); (Sharpe, Charles C. (1999)

Advance directives have considerable moral importance and provide a number of benefits. Firstly, it relieves the family members from the pressure of having to take important medical decisions regarding life and death and puts the entire responsibility on the patient. Secondly, it promotes self-determination and autonomy of the patients. Thirdly it promotes the well-being of the patients by protecting them from expensive, futile and intrusive medical treatments. It also serves altruism by giving health care providers and surrogate decision makers the authority to end any kind of treatment that would place a huge emotional and financial burden on family members. Advance directives help many terminally ill patients or otherwise healthy people to plan ahead for their eventual death. It also helps to strengthen relationships by increasing communication between near and dear ones and settles the issue of "unfinished business." (Johnstone, 2004); ("Advance Directives.," n. d.)