Advance Directives for Medical Care — A Case for Greater Use

Harvard University, Cambridge, Massachusetts, United States
New England Journal of Medicine (Impact Factor: 55.87). 04/1991; 324(13):889-95. DOI: 10.1056/NEJM199103283241305
Source: PubMed


BACKGROUND. Advance directives for medical care and the designation of proxy decision makers to guide medical care after a patient has become incompetent have been widely advocated but little studied. We investigated the attitudes of patients toward planning, perceived barriers to such planning, treatment preferences in four hypothetical scenarios, and the feasibility of using a particular document (the Medical Directive) in the outpatient setting to specify advance directives.
We surveyed 405 outpatients of 30 primary care physicians at Massachusetts General Hospital and 102 members of the general public in Boston and asked them as part of the survey to complete the Medical Directive.
Advance directives were desired by 93 percent of the outpatients and 89 percent of the members of the general public (P greater than 0.2). Both the young and the healthy subgroups expressed at least as much interest in planning as those older than 65 and those in fair-to-poor health. Of the perceived barriers to issuing advance directives, the lack of physician initiative was among the most frequently mentioned, and the disturbing nature of the topic was among the least. The outpatients refused life-sustaining treatments in 71 percent of their responses to options in the four scenarios (coma with chance of recovery, 57 percent; persistent vegetative state, 85 percent; dementia, 79 percent; and dementia with a terminal illness, 87 percent), with small differences between widely differing types of treatments. Specific treatment preferences could not be usefully predicted according to age, self-rated state of health, or other demographic features. Completing the Medical Directive took a median of 14 minutes.
When people are asked to imagine themselves incompetent with a poor prognosis, they decide against life-sustaining treatments about 70 percent of the time. Health, age, or other demographic features cannot be used, however, to predict specific preferences. Advance directives as part of a comprehensive approach such as that provided by the Medical Directive are desired by most people, require physician initiative, and can be achieved during a regular office visit.

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    • "The majority of patients suffering from chronic diseases or serious medical conditions prefer to decide and express in advance their preferred medical interventions and their views about the use of life-sustaining care interventions (Emanuel et al. 1991; Edinger and Smucker 1992; Gates et al. 1993; Kelner et al. 1993). Studies from USA and Europe revealed that patients usually prefer to discuss advance directives early in the patient-physician relationship . "
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    ABSTRACT: Advance directives are specific competent consumers' wishes about future medical plans in the event that they become incompetent. Awareness of a patient's autonomy particularly, in relation to their right to refuse or withdraw treatment, a right for the patient to die from natural causes and interest in end of life issues were among the main reasons for developing and legalizing advance medical directives in developed countries. However, in many circumstances cultural and religious aspects are among many factors that can hamper implementation of advance directives. Islam and Muslims in general have a good understanding of death and dying. Islam allows the withholding or withdrawal of treatments in some cases where the intervention is considered futile. However, there is lack of literature and debate about such issues from an Islamic point of view. This article provides the Islamic perspective with regards to advance medical directive with the hope that it will generate more thoughts and evoke further discussion on this important topic.
    Full-text · Article · May 2013 · Medicine Health Care and Philosophy
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    • "Despite attempts to increase completion rates, fewer than one quarter of patients have an advance directive that specifies their personal choices about end-of-life care options (L. Emanuel, Barry, Stoeckle, & Emanuel, 1991). Psychologists are accustomed to speaking with patients about issues of their own mortality, and at appropriate times can encourage advance care planning and completion of advance directives that are consistent with their personal values and can later guide their medical care. "

    Full-text · Article · Jan 2013
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    • "Next to these changes we think the debate on self-binding can learn from the general debate on advance directives for health care (Emanuel et al., 1991). In addition to advance directives which document the wishes of patients about health care and treatment in case they lose decision-making capacity, the so-called values history has been proposed (Doukas & Gorenflo, 1993; Doukas & McCullough, 1991). "
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    ABSTRACT: In certain cases of chronic mental illness (for example bipolar disorder) a self-binding directive or Ulysses contract may be a helpful intervention to prevent harm to the person him- or herself and/or others. By choosing such an arrangement, the patient can indicate when and how mental health professionals may intervene against his or her will and provide indicated care which may lead to an improvement of the patient's mental condition. In the Netherlands, since 2008 the Compulsory Admissions Act has been amended and now includes a paragraph on self-binding. Starting from the Dutch debate and statutory regulation of self-binding in mental health care, a number of issues with broader relevance are discussed, particularly as these pertain to the legal regulation and juridification of self-binding. It is argued that too many detailed rules are a threat to increasing patient empowerment.
    Full-text · Article · Dec 2011 · International Journal of Law and Psychiatry
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