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.     

Advance directives and personality-changing illness

An advance decision (AD) to refuse treatment allows an individual to express his/her wishes regarding future treatment in the event of losing capacity to make decisions. Relevant and applicable ADs are legally binding, even when refusal of the specfied treatment will lead to the patient's death; but health professionals are required under the Mental Capacity Act to consider a number of factors in deciding whether a patient's AD should be followed. The decision for the health professional is not always clear-cut. For example, what happens when Alzheimer's changes an indivdual's personality so much that they seem to be a different person: does their previous decision still stand? This article examines the criteria to be considered in such a case, and highlights the wider principles to be followed in making any decision on whether to follow an individual's instruction to refuse treatment.     

Advance directives and assisted suicide

Kemper and Murtaugh calculate what they term “lifetime use of nursing home care.” This is a measure of the time spent by the average person in a nursing home over a lifetime. Their conclusion, in qualitative form, is that the risk of entering a nursing home and spending a long time in a nursing home is “substantial” (1).     

Advance directives and community-dwelling older adults

Advance directives (ADs) are documents that allow competent individuals to set forth their medical treatment wishes and/or to name a proxy in the event that they lose the capacity to communicate these decisions in the future. Despite the benefits of and support for such documents, very few people have completed an AD. This posttest-only experimental study examined whether an individualized intervention given to half of the older adults who attended an educational session increased the discussion and/or completion of ADs. Of the 74 participants, 25.7% (n = 19) completed an AD. There were no significant differences between control and intervention groups on the discussion and/or completion of ADs. Multivariate analysis indicated that perceived barriers were significantly associated with the discussion and completion of ADs. Content analysis revealed that major barriers to discussion and completion include procrastination and a reluctance to think about deteriorating health status and/or death.     

Advance directives: legal remedies and psychosocial interventions

Although the legal basis to refuse life supports is firmly embedded in the laws of all 50 states, there is evidence that a gap exists between patients preferences and physicians actions. Patients and their families have increasingly begun to turn to the courts for redress, requesting damages when a physician has ignored their request to forgo life-sustaining treatment. This article explores the reasons why patients end-of-life medical choices are often ignored by the medical profession and the results of recent attempts to remedy these situations through the courts. Implications for practice are discussed, including practical suggestions for increasing the likelihood that a patient's wishes will be respected by medical providers.     

Advance directives: the New Zealand context

Advance directives convey consumers' wishes about accepting or refusing future treatment if they become incompetent. They are designed to communicate a competent consumer's perspective regarding the preferred treatment, should the consumer later become incompetent. There are associated ethical issues for health practitioners and this article considers the features that are relevant to nurses. In New Zealand, consumers have a legal right to use an advance directive that is not limited to life-prolonging care and includes general health procedures. Concerns may arise regarding a consumer's competence and the document's validity. Nurses need to understand their legal and professional obligations to comply with an advance directive. What role does a nurse play and what questions arise for a nurse when advance directives are discussed with consumers? This article considers the cultural dimensions, legal boundaries, consumers' and providers' perspectives, and the medical and nursing positions in New Zealand.