advance directives

Introduction

A document in which a person who has decision-making capacity states choices for medical treatment, or designates an individual for this purpose for use at a time when he/she no longer has decision-making capacity.

Thus advance directives are widely believed to be a safeguard of autonomy if a patient is to lose decision-making capacity.

It is an umbrella term that includes living will & health care proxy.

The Physician Orders for Life-Sustaining Treatment (POLST) is appropriate for the purpose.

An advance directive is NOT to be used as a basis for making medical decisions while the patient still has decision-making capacity (i.e. advance directives ONLY become operative when the patient has lost decision-making capacity.

The Patient Self-Determination Act of 1991 requires that all facilities receiving Medicaid or Medicare funding provide patients with written information regarding advance directives.

Drawbacks:

• discussion between patients & physicians infrequently held
  • advance directives sometimes viewed as a substitute for goals of care
• most discussion focus on interventions, rather than outcomes & willingness to take risks
• patients misunderstand the outcomes of life-sustaining treatments
• goals of care are too frequently not transferred across care settings
• as a result advance directives have had little impact on end of life care

see Guidelines for advance directive discussion

Management

• introduce the concept of advance directives by asking an open-ended question "What brings you happiness?"
• also see surrogate decision maker
• when there is an apparent conflict between the patient's advance directives & the surrogate decision maker, the values of the patient need to be revisited
• a formal meeting of the surrogate decision maker, family members, & the health care team should be held to discuss the patient's clinical status, prognosis, treatment options, & to explore the surrogate decision maker's understanding of the patient's advance directives (see surrogate decision maker)
• when no surrogate decision maker has been appointed, honor the patient's advance directives
• when there are no advance directives, no surrogate decision maker has been appointed, & there is disagreement among family members, organize a family meeting

* when there is a language barrier, use a professional medical interpreter

Notes

• ~20% of US adults have advance directives
• only 1/2 of cancer patients who die in the hospital have discussions of advance directives
• advance directives documented in a minority of patients after ischemic stroke
• written advance directives more common among dominant North American culture than in minority groups
• blacks less likely that other ethnic groups to complete advance directives
  • mistrust in healthcare system
  • discomfort discussing death
  • greater preference for life-sustaining treatment
• appears to be a disconnect between dialysis patients' expressed values, largely comfort focused, & their engagement in advance care planning & end-of-life care, which reflects a focus on longevity

More specific terms

• code status
• durable power of attorney (DPoA)
• living will

Additional terms

• advance care planning
• guidelines for advance directive discussion
• medical ethics
• Physician Orders for Life-Sustaining Treatment (POLST)

Patient information

advance directives patient information