Lost in Translation: The Unintended Consequences of Advance Directive Law on Clinical Care

University of California, San Francisco, San Francisco Veterans Affairs Medical Center, USA.
Annals of internal medicine (Impact Factor: 17.81). 01/2011; 154(2):121-8. DOI: 10.1059/0003-4819-154-2-201101180-00012
Source: PubMed


Advance directive law may compromise the clinical effectiveness of advance directives.
To identify unintended legal consequences of advance directive law that may prevent patients from communicating end-of-life preferences.
Advance directive legal statutes for all 50 U.S. states and the District of Columbia and English-language searches of LexisNexis, Westlaw, and MEDLINE from 1966 to August 2010.
Two independent reviewers selected 51 advance directive statutes and 20 articles. Three independent legal reviewers selected 105 legal proceedings.
Two reviewers independently assessed data sources and used critical content analysis to determine legal barriers to the clinical effectiveness of advance directives. Disagreements were resolved by consensus.
Legal and content-related barriers included poor readability (that is, laws in all states were written above a 12th-grade reading level), health care agent or surrogate restrictions (for example, 40 states did not include same-sex or domestic partners as default surrogates), and execution requirements needed to make forms legally valid (for example, 35 states did not allow oral advance directives, and 48 states required witness signatures, a notary public, or both). Vulnerable populations most likely to be affected by these barriers included patients with limited literacy, limited English proficiency, or both who cannot read or execute advance directives; same-sex or domestic partners who may be without legally valid and trusted surrogates; and unbefriended, institutionalized, or homeless patients who may be without witnesses and suitable surrogates.
Only appellate-level legal cases were available, which may have excluded relevant cases.
Unintended negative consequences of advance directive legal restrictions may prevent all patients, and particularly vulnerable patients, from making and communicating their end-of-life wishes and having them honored. These restrictions have rendered advance directives less clinically useful. Recommendations include improving readability, allowing oral advance directives, and eliminating witness or notary requirements.
U.S. Department of Veterans Affairs and the Pfizer Foundation.

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Available from: Charles P Sabatino, Oct 31, 2014
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    • "Discrimination can be a factor in decision making, with the role often falling to the 'next of kin' owing to a powerful legal precedent, in neglect of the position of same-sex partners. In many countries, same-sex partners are not afforded the legal protection that is offered by marriage, although steps have been made regard-ing their rights in this area (Castillo et al, 2011). Stein and Bonuck (2001) argue that relevant information to promote awareness of the medical, psychosocial, and legal implications of sexual preferences should be included in programmes and policies on end-of-life care. "
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    ABSTRACT: Negative social attitudes, discrimination, and homophobia affect gay, lesbian, bisexual, and transgender (GLBT) individuals during their lifetimes. These experiences can affect how these individuals access health services and interact with health professionals, resulting in adverse outcomes compared with their heterosexual counterparts. End-of-life experiences can also be shaped by these factors. There are implications for health professionals in terms of equity of access to targeted health care, preventive screening, and visibility in policy, as well as in principles of inclusiveness, dignity and respect, and competence in care. This article takes a brief look at some of the issues specific to the end-of-life care of GLBT individuals, using a case study as an illustrative example. Holistic care at the end of life is a familiar concept to palliative care nurses, but it is important to place greater emphasis on considering competence in aspects of care relating to sexuality.
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    ABSTRACT: Purpose. This study assesses the impact of Advance Directives (ADs) on end-of-life costs, drawing on administrative data from a single health care organization located in Milwaukee, Wisconsin (Independent Care Health Plan, or iCare). Background. As part of ongoing Medicaid and Medicare rate reform efforts, greater use of ADs among plans and providers is being considered to better control costs and enhance health outcomes. Approach. Drawing on decedent-member descriptive and cost data, OLS regression is used to analyze the relationship between AD use and subsequent costs for a single health care plan. Results. The analysis does not provide evidence of a significant relationship between AD use and end-of-life costs when patient health is controlled for the sample. Conclusions. There was no evidence within the iCare data to support a relationship between the presence of ADs and lower end-of-life costs.
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    ABSTRACT: CONTEXT: Advance directives are poorly understood in Japanese nursing homes. In April 2006, additional funding for end-of-life care became available as the first support for terminal care at Japanese nursing homes. OBJECTIVES: The objectives of this study were to investigate the adoption of advance directives by Japanese nursing homes, the effect of additional funding for end-of-life care in nursing homes from long-term care insurance on the use of advance directives, and the types of directives used. METHODS: A nationwide questionnaire survey of nursing homes was performed in Japan. The participants were 913 nursing homes. We investigated the prevalence of advance directives, details of the directives, and demographic data of the responders. RESULTS: Advance directives were used in 58.4% of nursing homes. The timing of introduction of the directives and the results of multivariate analysis at the facility level suggested a relation between the availability of additional funding for end-of-life care and the adoption of advance directives. Most nursing homes used instructional directives, especially directives providing an explanation and informed consent for end-of-life care in the nursing home. CONCLUSION: More than half of the Japanese nursing homes have introduced advance directives, and additional funding for end-of-life care is related to their introduction. Most nursing homes have adopted instructional directives, especially those providing an explanation and informed consent regarding end-of-life care at the nursing home.
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