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…...
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References
Brown, L.D. (2012). Stealing on insensibly: End of life politics in the United States. Health Economics, Policy and Law, 7(4), 467-83. doi: http://dx.doi.org/10.1017/S1744133112000254
Eggertson, L. (2013). Doctors, patients urged to discuss advanced care plans. Canadian Medical
Advanced directive may be one of the most important and underutilized tools in estate planning and health planning. This is partially due to the stigma that people have about advanced directives, as if, by planning how to deal with health issues, they are somehow going to cause health problems. However, the reality is that most people will encounter at least one medical emergency during their lifetime. In the event that the health event renders a person unable to communicate his or her wishes, the advanced directive is a method of ensuring that the patient is still able to communicate his or her wishes. This is specifically relevant in scenarios where third parties may have to make decisions about whether to provide or withhold life-saving treatments.
There are a number of different documents that fall under the rubric of advanced directives. The term encompasses all legally binding written documents that describe an…...
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References
American Bar Association. (Unk.). Myths and facts about health care advance directives.
Retrieved November 14, 2013 from ABA website:
American Hospital Association. (2012). Put it in writing: Questions and answers on advanced directives. Retrieved November 14, 2013 from AHA website: http://www.aha.org/content/13/putitinwriting.pdf
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 CP 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. CP 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 CP. Conflicts often crop up when the patient's family members, friends or relatives who have a vested interest…...
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References
American Academy of Orthopaedic Surgeons. (2006) "Emergency Care and Transportation
of the Sick and Injured" Jones & Bartlett Publishers.
Billings, Diane M. (2008) "Lippincott's Content Review for NCLEX-RN." Lippincott
For example, Wissow and colleagues (2004) collected gender, age, ethnicity, and levels of clinic/ED use. This information may provide valuable insight into who is most likely to create an advanced directive in response to the intervention. The time frame for the study was not mentioned or how long after the intervention the survey instrument would be presented to intervention participants. This could be relevant because some individuals exposed to the intervention may decide to create an advanced directive right away, while others may wait weeks or months before finally making the decision to put into writing their care preferences.
eferences
Hunter-Johnson, L. (2014). Evaluating advanced directive promotion. University of South Alabama.
Wissow, L.S., Belote, a., Kramer, W., Compton-Phillips, a., Kritzler, ., & Weiner, J.P. (2004). Promoting advance directives among elderly primary care patients. Journal of General Internal Medicine,…...
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References
Hunter-Johnson, L. (2014). Evaluating advanced directive promotion. University of South Alabama.
Wissow, L.S., Belote, a., Kramer, W., Compton-Phillips, a., Kritzler, R., & Weiner, J.P. (2004). Promoting advance directives among elderly primary care patients. Journal of General Internal Medicine, 19(9), 944-51.
Cae Planning Analysis
In eality, sound healthcae-elated advanced planning is a continuous convesation, involving pioities, values, QOL (quality of life) and what one's life means. Tool kits, in this context, compise vaious self-help esouces, woksheets, and ecommendations. They aid individuals in pefoming the moe complex tasks of identifying, confiming, and shaing impotant facts with an individual faced with a seious ailment (Ameican Ba Association, 2005). Iespective of whethe the individual is teminally ill o suffeing fom an acute ailment o chonic, long-tem ailment, advanced cae planning (ACP) is capable of facilitating the alleviation of unnecessay suffeing, impoving QOL and offeing a bette gasp of decision-elated challenges faced by the ailing individual, his/he family, and othe caegives. Advanced cae plans may be implemented at any junctue in the patient's life and must be updated when changes occu in patient cicumstances. A peson who contacts a pogessive disease that leaves him/he disabled…...
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references? A Study of the U.S. Medicare Population. Medical care, 45(5), 386.
Supervision: When to Use Directive Control Behaviors
This paper is about many different aspects of effective supervision, training and evaluation, but the main concern here is control. It can be assumed that the supervisor has control over the supervisory situation, but this would be an oversimplification of the relationship between a line employee and their direct boss. Control is a shared entity because though the supervisor may determine the course an employee must take, the employee decides whether they will follow that direction or not. Thus, the supervisor must prove to the employee that they are competent in the job before they can expect the employee to follow direction.
This is the stance taken by directive control behaviors. A supervisor who uses directive control behaviors has to be a subject matter expert. If they cannot claim an expertise in the elements that the job entails then they are less likely to have…...
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Pistole and Fitch (2008) examined the role of attachment in supervision. The findings in this study were much like those of the cultural study. Two factors influenced the role attachment played in the supervisory relationship: a culture that valued attachment, or a person who did not feel confident in the job that they were doing. The second type of employee seems to thrive under the vertical, directive style of leadership and have productivity decreases when forced to complete a task with little direction (Pistole & Fitch, 2008). This meshes well with other research which suggests what the appropriate role of directive control behaviors are.
Directive control also calls for a leader who is charismatic enough to generate the trust necessary for the directive relationship to succeed. The worker must be able to see that the supervisor has confidence in their skill level before that leader will be accepted. Einstein and Humphreys (2001) looked at how directive leaders were perceived by their subordinates. The most important part of the relationship, according to the research, was the belief by the employees that the leader was an expert. This led to a belief that the direction that was being received was appropriate to meet the set goals. The researchers did find that a leader must be willing to move from "directive to persuasive to involving to inspirational styles of leadership" as the competency and confidence of the employees increased. If the supervisor remained in a directive role for too long then productivity of the employees would decrease.
These studies bear out two points that are important for understanding the role of directive supervisory behavior. First, there are certain groups of people that will generally feel more comfortable when the supervisor takes a more directive role. Second, directive leadership has a very specific window of success. It needs to be used in the correct situations.
With regard to the medication administration itself, in a life saving circumstance, which this clearly is not the weight of the potential for depression of respiration and cardiac status is clearly indicated, yet it would seem unethical under these circumstances, if the review of the documentation proves its validity and clearly indicates the patients wishes, to deny at least the smallest dosage (2mg) of ordered Morphine to reduce the pain and potentially allow the patient to regain calm, which will clearly improve his status with regard to short-term treatment.
If the fear of doing harm, drives every medical decision, based on the extreme notion that all patients can be saved under all circumstances then bioethical decisions are futile. The observations and communications of others in the immediate vicinity to care, including the family, other nurses, support staff and most importantly the orders of the doctor to administer palliative care for…...
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References
Andre, J. (2002). Bioethics as Practice. Chapel Hill, NC: University of North Carolina Press.
Mantz, a. (2002). Do Not Resuscitate Decision-Making: Ohio's Do Not Resuscitate Law Should Be Amended to Include a Mature Minor's Right to Initiate a DNR Order. Journal of Law and Health, 17(2), 359.
Saunders, D.E. (2003). Removing the Mask. The Hastings Center Report, 33(2), 12.
According to this second view, contemporaneous autonomy trumps precedent autonomy because honoring precedent autonomy imposes preferences and values of a different person, the formerly competent self (Buccafumi, p. 14).
The role that patient's families, doctors, health aides, pastors, chaplains and administrators, health educators and others play is crucial. Few people have executed an advanced directive, much less appointed a healthcare power of attorney by the time they enter a hospital with a debilitating condition. An informed consent form only marks the fact that a conversation has taken place in a health facility. The process that needs to or ought to take place concerning a patient's wishes and ensure one's wishes are empowered are part of the process involved as one fills out the advanced directive for themselves. In California the state has consolidated statutes for advanced directives and added some rights and included the best features of past laws. A…...
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REFERENCES WHICH I DID NOT USE (JUST for YOUR INFO, NOT to BE INCLUDED in THIS PAPER)
American Nurses Association. (1985). American Nurses
Association Code for Nurses with Interpretive Statements, Section 1.1. Washington, DC:ANA.
Fishback, R. (1996). Harvard Medical School Division of Medical Ethics. Care Near the End of Life. [Online]. Available: www.logicnet.com/archives/file2001.php.
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…...
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References
Burnell, G.M. (1993). Final Choices: To Live or to Die in an Age of Medical Technology. New York: Insight Books.
Fisher, C.B. (2002). A Goodness-of-Fit Ethic for Informed Consent. Fordham Urban Law Journal, 30(1), 159.
Galambos, C.M. (1998). Preserving End-of-Life Autonomy: The Patient Self-Determination Act and the Uniform Health Care Decisions Act. Health and Social Work, 23(4), 275.
Hardwig, J. (2000). Spiritual Issues at the End of Life: A Call for Discussion. The Hastings Center Report, 30(2), 28.
The hospital should always defer to the patient and family that has an advanced directive in place, and if the patient cannot speak for themselves but has an advanced directive, then a proxy must make the decision. The only case where the hospital should be allowed to make the decision on futile care is in the absence of a proxy, in the absence of an advanced directive, and only if it is in the best interest of the patient.
In this psychological-based model, the healthcare professional and hospital is put in the position of negotiating with the family and/or patient. Burns and Truog (2007) state that in these situations the healthcare professional should always follow the wishes of the patient's family in futile care efforts (Burns & Truog, 2007). However, that view places a burden on the healthcare professional to compromise medical principles when that professional deems the care to…...
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References
Burns, J., & Truog, R. (2007). Futility: A Concept in Evolution. Chest, 1987-1993.
Forde, R. (1998). Who is to define the futility of treatment -- the patient or the physician? Tidsskr nor Laegeforen (Norwegian), 2652-2654.
Jonson, a., Seigler, M., & Winslade, W. (2002). Clinical Ethics 5th ed. New York, NY: McGraw-Hill.
Lachman, V. (2009). Ethical Challenges in Health Care: Developing Your Moral Compass. New York, NY: Springer Publishing.
Nursing and Ethical Choices
What are the utilitarian and Kantian justifications for Advance Directives?
The health care proxy and the living will are two ways in which a patient can express advance directives relating to health care and/or end of life treatment should that person become incapacitated. The utilitarian justification for advance directives is that the end justifies the means, or in other words the greatest good for the greatest number of people. If an advanced directive is given, it covers all the people involved and lets the patient's wishes be known ahead of time in case there comes a moment when the patient can speak for him or herself. The doctors and care givers will be obliged to accept this as the greatest good, because it relieves them of any duty to give care (if the directive has in place that it should be refused) and vice-versa. The Kantian justification for…...
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References
Edwin, A. K. (2010). Non-disclosure of medical errors an egregious violation of ethical principles. Ghana Medical Journal, 43(1): 34-39.
Gallagher, Thomas H. "A 62-Year-old Woman with Skin Cancer Who Experienced
Wrong-Site Surgery." (CIB, 65-71)
Philipsen, N. C., Soeken, D. (2011). Preparing to blow the whistle: A survival guide for nurses. The Journal for Nurse Practicioners, 7(9): 740-746.
It is also wise to have it reviewed by a doctor or attorney, the Family Doctor eb site suggests; that way you can be assured that what you wish to have done with you and to you if you become incapacitated is "understood exactly as you intended" (Family Doctor).
The advance directives are sensitive and private, and they are very important for seniors. But the advance directives can be controversial, so it is wise for older people to know the law and understand the facts. To wit, there have been rumors and falsehoods spread on the orld ide eb and elsewhere about the advance directives that are spelled out in the recent overhaul of the healthcare system. Former governor of Alaska Sarah Palin made news in the summer of 2009 by asserting that the advance directives in the healthcare overhaul created a "death panel" of bureaucrats who will "decide, based…...
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Works Cited
Binstock, Robert H., and George, Linda K. (2010). Handbook of Aging and the Social
Sciences. Maryland Heights, MO: Academic Press.
Black, Jane A. (2008). Notes: The Not-So-Golden Years: Power of Attorney, Elder Abuse, and Why Our Laws are Failing a Vulnerable Population. St. John's Law Review, 82(1), 289-314
Collier, Elizabeth. (2005). Latent age discrimination in mental health care. Mental Health
Patient is a 69-year-Old male who is refusing treatment for cancer. The following is a description of the patient.
Primary diagnosis: Malignant Neoplasm of Head, Face and Neck (C76.0) because this is the diagnosis that brought the patient into treatment (Hogston, 1997).
Patient's past medical history: Hypertension, hyperlipidemia, stomatitis, anemia, neutropenia. Patient had right radical neck dissection in 2012.
Current Medications: Carvedilol 12.5 mg. q.d.; Furosemide 40 mg q.d.
Social History: Patient is a former smoker who quit two years ago following cancer diagnosis. He is married with children.
Current Issue: Patient is refusing to engage in further treatment regarding his cancer (chemotherapy and radiation) stating that he is tired of the untoward effects of treatment. Patient wants information regarding other options.
Complicating factors:
A. Patient's family does not agree with his decision to stop treatment.
B. Patient does not have an advanced directive or living will.
7. Possible Secondary Diagnoses:
A. Depressive Disorder (eactive Depression; F32).
B. Adjustment Disorder with…...
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References
Auning, E., Selnes, P., Grambaite, R., Saltyt? Benth, J., Haram, A., Lovli Stav, A., ... & Aarsland, D. (2015). Neurobiological correlates of depressive symptoms in people with subjective and mild cognitive impairment. Acta Psychiatrica Scandinavica, 131(2), 139-147.
Ellershaw, J., & Wilkinson, S. (2011). Care of the dying: A pathway to excellence. New York:
Hatfield, R. C. (2014). The everything guide to coping with panic disorder. Avon, MA: Adams.
Hogston, R. (1997). Nursing diagnosis and classification systems: a position paper. Journal of Advanced Nursing, 26(3), 496-500.
THE SCHIAVO DILEMMA The Schiavo DilemmaIn my opinion, the form of an advance directive that would have been ideal in this case, i.e. when it comes to communicating Ms. Schiavos wishes, would have been a living will. In essence, a living will, in the words of Kirtland and Jackson (2021), could be conceptualized as a written, legal document that spells out medical treatments you would and would not want to be used to keep you alive, as well as your preferences for other medical decisions, such as pain management or organ donation (95). This would have been the best advanced directive option in this particular scenario owing to the fact that it would have clearly and in no uncertain terms spelt out Ms. Schiavos wishes about the interventions she would have desired (i.e. in as far as being kept alive is concerned) if she were to be in a state…...
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ReferencesDeMartino, E. S., Dudzinaki, D. M., Doyle, C. K., Sperry, B. P., Gregory, S. E., Siegler, M., Sulmasy, D. P., Mueller, P. S. & Kramer, D. B. (2017). Who Decides When a Patient Can’t? Statutes on Alternate Decision Makers. N Engl J Med, 376(15), 1478-1482.Wolfson, J. (2006). The Basis for Decisions to End Life. The Schiavo Dilemma: An Essay by the Special Guardian Ad Litem. Clin Intery Aging, 1(1), 3-6.
Life Care
Difficult Situations as a Nurse Practitioner
The scenario for the nurse practitioner centers on Angela Smith and her family. Angela is a 55-year-old who suffered a stroke and admitted after neighbors noticed some really odd behaviors. The situation was further complicated when Angela suffered a respiratory arrest and required mechanical ventilation and after a second CT scan the team found that she bleed into the ventricles and brainstem which may have caused irreversible brain damage. Her condition is quite serious and there must be a decision made about how to proceed with the care for Angela. It is likely that she will need long-term ventilation and PEG and the neurological team suspects that the brain damage is irreversible.
The most difficult aspect to this scenario is that there is no advanced directive and the family is being indefensibly optimistic regarding the potential for recovery. In fact, the patient's family, her…...
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References
Burchum, J. (2002). Cultural Competence: An Evolutionary Perspective. Nursing Forum, 5-15.
Campinha-Bacote, J. (2002). The Process of Cultural Competence in the Delivery of Healthcare Services: A Model of Care. Journal of Transactional Nursing, 181-184.
Tervalon, M., & Murray-Garcia, J. (1998). Cultural Humility vs. Cultural Competence: A Critical Distinction in Defining Physician Training Outcomes in Multicultural Education. Journal for Health Care for the Poor and Underserved, 117-125.
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