A nursing perspective on advance directives.

The nurse's role in implementing the Patient Self-Determination Act is often unclear. This article describes the clinical use of advance directives, discusses related ethical concepts, and identifies methods nurses could use for initiating discussions about advance directives.     

Advance directives in critically ill cancer patients

Although advance directives have been used since the 1970s, the discussion of these documents has become more common since the enactment of the Patient Self-Determination Act in 1991. This study evaluated the frequency of advance directives in critically ill patients at a tertiary cancer center and found that cancer patients had a relatively low completion rate of advance directives (27%). The finding that advance directives were more common among Caucasians than other ethnic groups signifies the importance of considering cultural differences when addressing end-of-life issues with patients. The documents also were found more often in older patients with serious diseases. The relationship between hospital mortality and advance directives is complex. The most seriously ill patients and patients with leukemia had the highest mortality and the highest rate of advance directives. Further research on the interactions among mortality, advance directives, and severity of illness is needed. This research contributes to the body of knowledge available on advance directives and particularly sheds light on advance directives in critical ill cancer patients.     

Recent developments in health law relevant to health care providers.

Because health law is changing continually, clinicians must be updated periodically. This article discusses two significant legal developments: the defeat of court-ordered cesarean sections and the new Patient Self-Determination Act. A decision reached by the Court of Appeals for the District of Columbia asserted that medical decisions on behalf of a woman and her fetus should be made by the pregnant woman if she is conscious and alert. Although this decision does not supply all the answers, it reiterates judicial support for the primacy of a woman's rights when her welfare is endangered by a procedure designed to safeguard a fetus. The Patient Self-Determination Act, effective December 1991, requires health care providers at hospitals and other sites to supply all adult patients with written information advising them of their rights, to explain the provider's policy for implementing those rights and to document any advance directives supplied by patients.     

King's theory as foundation for an advance directive decision-making model

This article discusses the utilization of King's conceptual system, transaction process model, and theory of goal attainment as foundations for an advance directive decision-making model. Research has shown nurses may be educationally unprepared, experience conflicts between beliefs and actions, or resist the responsibility to address advance directives and end-of-life issues. Nurses, especially nurse practitioners providing primary care, are in positions to facilitate the process. By understanding and incorporating this model into practice, both the nurse and the client may achieve mutual goal attainment resulting in both increased client autonomy and Patient Self-Determination Act compliance.     

Advanced directives. In search of self-determination

Patients are seeking self-determination in health-care through the use of advanced directives. The author discusses advanced directives focusing on patient rights in decision making, autonomy, and the right to refuse life-sustaining treatment. Highlighted is the Patient Self-Determination Act of 1990, including strategies for its implementation in healthcare agencies.     

Advance directives and dementia

Since the 1990 Patient Self-Determination Act, increasing numbers of adults are completing advance directives (ADs), but unfortunately many adults seen in a dementia evaluation program have not completed an AD. This article discusses the issue of individuals with dementia completing ADs. Situational factors that frame this issue are the stage of dementia, degree of certainty of an individual's wishes for end-of-life care, the decision-making act required by care providers, and the degree of contentment or distress experienced by an individual with dementia. Several investigators have demonstrated successful completion of ADs by individuals with mild and moderate dementia. A nurse's knowledge about the stages of dementia is essential to helping an individual through the AD decision-making process. Nurses caring for individuals with dementia should assess decision-making context; recognize the emotions of family, friends, and staff; understand the substance and logic of AD requests; and support individuals and their decisions.     

The Patient Self-determination Act: has it reached the end of its life?

The Patient Self-determination Act requires that patients be informed in writing of their right to accept or refuse treatment and the right to an advance directive. For the past 15 years, hospitals have been providing these written materials, yet advance directives are still not adequately directing end-of-life care. Barriers and facilitators to implementation of this law are discussed, as well as the role of nursing management in meeting its true intent.     

Advance Directives in Skilled Nursing Facility Residents Transferred to Emergency Departments

OBJECTIVE: Ten years have passed since Congress enacted the Patient Self-Determination Act to promote the use of advance directives (ADs). This study was performed to determine the frequency, type, demographic distribution, and utility of ADs that accompany residents of skilled nursing facilities (SNFs) transferred to emergency departments (EDs). METHODS: This was an observational, cross-sectional cohort of SNF residents, transferred to two urban, academic EDs. Chart review and physician interviews were conducted on consecutive patients arriving during 12-hour data collection shifts. RESULTS: Among 715 patients entered, 315 [44%, 95% confidence interval (95% CI) = 40% to 48%] had an AD. Advance directives were significantly more prevalent among white (50%) than African American (34%) or Hispanic (39%) patients (p < 0.001), and varied from 0% to 94% among SNFs. Of the 315 patients with ADs, do-not-resuscitate (DNR) orders were the most prevalent (65%, 95% CI = 58% to 69%). Although 75% (95% CI = 69% to 81%) of the DNR orders addressed cardiopulmonary resuscitation (CPR), only 12% (95% CI = 8% to 16%) addressed intubation. Among 39 patients who required intubation or CPR, 44% had ADs, 82% (95% CI = 57% to 96%) of which were deemed useful. CONCLUSIONS: Despite a decade of legislation promoting their use, ADs are lacking in most SNF residents transferred to EDs for evaluation and in most settings in which a clinical indication exists for intubation or CPR. Variation in their prevalence appears to be associated with both ethnicity and SNF origin. Although about three-fourths of DNR ADs addressed CPR, only about one in ten offered guidance regarding intubation. When available, ADs are used in most instances to guide emergency care.     

Do-not-resuscitate and stratification-of-care forms in Rhode Island.

Congress passed the Patient Self-Determination Act of 1990 to ensure that patients are informed of their rights to express healthcare preferences in advance of loss of capacity. Thus, a patient may elect to forgo cardiopulmonary resuscitation in favor of a treatment approach that favors comfort over survival. Do-not-resuscitate and stratification-of-care forms provide a means for expression of healthcare preferences in hospitals. These forms can often guide the important discussion of healthcare preferences. Unfortunately, no clear standard exists for what should be included in do-not-resuscitate or stratification-of-care forms that institutions seeking to improve in this vital area of practice could use for guidance. Existing forms in use at adult general hospitals throughout Rhode Island were reviewed.     

Advance directives.

Advance directives concerning treatment have been firmly established in our society. Reactions to them, however, are varied, especially when the health care provider possesses a different belief about the care, or non-provision of care, in a particular situation. It is important for the neuroscience nurse to be in touch with thoughts and feelings concerning a patient's treatment choice, and, when necessary, to seek input and support about those concerns. Clearly, if the nurse cannot carry out the patient's wishes, the nurse can use applicable state law provisions supported by the Patient Self-Determination Act, and request not to participate in the care of that patient. If, however, the neuroscience nurse does provide care, ethically and legally it must be done in accordance with the patient's expressed choices.     

Could lack of clarity in written advance directives contribute to their ineffectiveness? A study of the content of written advance directives.

Since 1991, advance directives have failed to have a significant impact on end of life care. One reason is that despite widespread interest in these documents, few individuals have chosen to issue advance directives. Another reason reported in several studies is that the conditions under which the patient intended the directives to apply are unclear as are some of the treatments requested or declined. The purpose of this study was to describe instructions commonly included in written advance directives concerning the conditions under which the directives should apply and the treatments that are requested or declined. Five hundred consecutive closed medical records were reviewed from the medical and surgical departments of an urban hospital. These records produced 40 (8%) advance directive documents. Patient instructions indicating when the directives should take effect and which treatments should be declined or provided were summarized. Nurses and other health professionals can use this information to assist in patients in making their advance directives as clear as possible and to make patients more aware of the potential limitations of these types of written instructions.     

The Patient Self-Determination Act: the ethical dimensions.

Advanced, sophisticated technology, rising health care costs, and consumerism all combined to drive the development of the Patient Self-Determination Act. Ethical implications include, but are not limited, to the principles of autonomy and beneficence. Paternalism is also discussed as a compromise to autonomy. Caring is used to focus on the contextual perspective of both patients and nurses for ethical decision making. Implications for future ethical practice conclude the discussion.     

An educational intervention for advance directives.

In spite of the passage of the Patient Self-Determination Act in 1991, research indicates that providing information alone has not brought about a significant increase in the completion rates of advance directive (AD) documents. The purpose of this pilot study was to design, implement, and evaluate an interactive multimedia CD-ROM educational program on AD. Study subjects consisted of 31 volunteer elderly men and women in a senior citizens center. An interactive multimedia CD-ROM program was developed in phase I of the study. Subjects were administered on-line pretests and posttests. The effectiveness of the CD-ROM intervention was measured by AD attitude and knowledge changes. A program satisfaction scale was used, and an observer rated the subjects' use of the computer program. Subjects had a statistically significant change in posttest knowledge scores and a high degree of satisfaction and ease in using the computer program. The use of an interactive multimedia CD-ROM program with a touch-sensitive monitor to operate a computer-based AD program for senior citizens shows future promise.