For elderly patients who have no one to appoint as their proxy, completing a living will that outlines their wishes is preferable to not providing any information at all about care preferences. This is equally so for patients who want to provide their proxy with some guidance about their treatment preferences and end-of-life care wishes, including artificial nutrition, ventilator support, and pain management. A living will (LW) provides specific instructions to health care providers about particular kinds of health care treatment that an individual would or would not want to prolong life. Living wills are often used to declare a wish to refuse, limit, or withhold life-sustaining treatment when an individual is unable to communicate. All but three states (New York, Massachusetts, and Michigan) have detailed statutes recognizing living wills. The usefulness of LWs is limited, however, to those clinical circumstances that were thought of before the person became incapable of making decisions. If a situation occurs that the LW will does not address, providers and families may not know how to proceed and still respect the patient's wishes. Assuming that an individual completes both the LW and DPAHC, the proxy/agent may not be obligated to follow the wishes outlined in the LW; those instructions serve as a guide.
(Mezey, Fulmer, & Abraham, 2006, p. 268)
The nurses will then read the Nina Case Study as a lead in to the family meeting suggestion:
To respect Nina's right to self-determination and to insure that her future welfare is protected, a goodness-of-fit process of obtaining ethically acceptable advanced directives should include a series of information sharing sessions among Nina, her children, and the medical scientists during which: (a) the physicians provide Nina and her family with information about the anticipated course, nature of, and potential risks and benefits of the experimental treatment; (b) Nina provides the practitioners and her children with information to help them understand her value system, the way she evaluates physical or emotional pain, her views on the altruistic value of research participation, and other personal perspectives that would allow her children to make future decisions from her perspective; and - Nina's children share their moral philosophies on consent-relevant dimensions so that Nina and they can decide whether or not the advance directives can be carried out in a manner that honors everyone's value orientations. (46) This last step recognizes that Nina is also obligated to respect the values and welfare of her children. (Fisher, 2002, P. 159)
From this they will help formulate a plan to help families see the wisdom of having such meetings to meet the needs of all individuals including the dying patient.
The close of the presentation will include the development of a set of directives, associated with the following three directives, which also outline the purpose and objectives of the in-service;
1. Allowing individuals to provide directions about the kind of medical care they do or do not want if they become unable to make decisions or communicate their wishes.
2. Providing guidance for health care professionals and families with regard to health care decisions that reflect the person's wishes should that person be unable to make health care decisions.
3. Providing immunity for health care professionals and families from civil and criminal liability when health care professionals follow the advance directive in good faith. (Mezey, Fulmer, & Abraham, 2006, p. 267)
Observable outcomes of implementing such a program would be to improve the comfort level of all involved with regard to discussion and resolutions of end of life issues. The presentation will also allow nurses a better understanding of the importance of Advanced directives documentation and the need for patients and families to fully understand them, to an even greater degree that consent forms where procedures have been fully explained to patients by a physician and/or surgeon.
Please respond to the following questions with your impression and/or suggestions for the above in-service presentation:
What are the three most significant lessons you have learned from this presentation.
Do you have a better understanding of advanced directives and end of life decision making?
What would you change about this presentation?
The development of programs and procedures that assist the most likely candidate to be responsible for beginning and sustaining end of life conversations with patients and their families, the nurse, are essential to real change in the development of Advanced Directives implementation.
Chronically ill elderly people and families living through the end of life of a family member deserve a better system than the one currently available. They depend on the health care system to serve their needs and certainly not to add to the burden of their or a loved one's final days. (Lynn & Adamson, 2003, p. 17)
Nurses deserve the opportunity to be comfortable with having and helping patients and families resolve essential questions with patients as they and most importantly patients need to be given every opportunity to retain their rights and make important decisions themselves. Simply supplying institutions with forms that remove legal responsibility, but are never fully explained to the patient and family is not enough to demonstrate real positive outcomes for patients.
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