Autonomy, liberalism and advance care planning. (1/32)

The justification for advance directives is grounded in the notion that they extend patient autonomy into future states of incompetency through patient participation in decision making about end-of-life care. Four objections challenge the necessity and sufficiency of individual autonomy, perceived to be a defining feature of liberal philosophical theory, as a basis of advance care planning. These objections are that the liberal concept of autonomy (i) implies a misconception of the individual self, (ii) entails the denial of values of social justice, (iii) does not account for justifiable acts of paternalism, and (iv) does not account for the importance of personal relationships in the advance care planning process. The last objection is especially pertinent in light of recent empirical research highlighting the importance of personal relationships in advance care planning. This article examines these four objections to autonomy, and the liberal theoretical framework with which it is associated, in order to re-evaluate the philosophical basis of advance care planning. We argue that liberal autonomy (i) is not a misconceived concept as critics assume, (ii) does not entail the denial of values of social justice, (iii) can account for justifiable acts of paternalism, though it (iv) is not the best account of the value of personal relationships that arise in advance care planning. In conclusion, we suggest that liberalism is a necessary component of a theoretical framework for advance care planning but that it needs to be supplemented with theories that focus explicitly on the significance of personal relationships.  (+info)

Decisions to treat or not to treat pneumonia in demented psychogeriatric nursing home patients: development of a guideline. (2/32)

Non-treatment decisions concerning demented patients are complex: in addition to issues concerning the health of patients, ethical and legal issues are involved. This paper describes a method for the development of a guideline that clarifies the steps to be taken in the decision making process whether to forgo curative treatment of pneumonia in psychogeriatric nursing home patients. The method of development consisted of seven steps. Step 1 was a literature study from which ethical, juridical and medical factors concerning the patient's health and prognosis were identified. In step 2, a questionnaire was sent to 26 nursing home physicians to determine the relative importance of these factors in clinical practice. In a meeting of nine experienced physicians (step 3), the factors identified in step 2 were confirmed by most of these professionals. To prevent the final guideline being too directive, a concept guideline that included ethical and legal aspects was designed in the form of a "checklist of considerations" (step 4). Experts in the fields of nursing home medicine, ethics and law reviewed and commented on the concept guideline (step 5). The accordingly adapted "checklist of considerations" was tested in a pilot study (step 6), after which all experts endorsed the checklist (step 7). The resulting "checklist of considerations" structures the decision making process according to three primary domains: medical aspects, patient's autonomy, and patient's best interest (see annex at end of paper).  (+info)

Physicians's reports on the impact of living wills at the end of life in Japan. (3/32)

CONTEXT: A growing number of Japanese people have completed advance directives, especially living wills, even though there is no legislation recognising such documents and little empirical research on their impact on clinical care at the end of life in Japan. OBJECTIVES: To investigate physicians' attitudes about living wills and their experiences with patients who had completed a living will and later died. DESIGN: Self administered survey and qualitative study using open question and content analysis. SETTING: Japan. PARTICIPANTS: Physicians known to have cared for a patient who had presented a living will prior to death. MEASUREMENTS: The physician's response to receiving a living will, communication about the living will, the impact of the living will on clinical care, demographics, and their opinion on advance directives, especially living wills. MAIN RESULTS: Fifty five per cent of respondents approved of advance directives in general, and 34% had more opportunities to communicate with a patient and his/her family after receiving the living will. Sixty nine per cent of the physicians who received a living will did not, however, change their course of therapy as a consequence of receiving the living wills. Based on the analysis, we identified three areas of concern in the comments on living wills: (1) concerns relative to patients, physicians, and families; (2) social context, and (3) clinical and administrative concerns. The physicians raised various topics for discussion; they tended to describe the issues from a clinical perspective. CONCLUSIONS: Our identified areas of concern should prove helpful in better understanding the clinical and ethical implications of living wills in Japan.  (+info)

Adherence to advance directives in critical care decision making: vignette study. (4/32)

OBJECTIVE: To explore health professionals' decision making in a critical care scenario when there is an advance directive. DESIGN: Qualitative study. SETTING: Scotland. PARTICIPANTS: Interviewees (n = 12) comprising general practitioners, hospital specialists, and nurses, and six focus groups (n = 34 participants) comprising general practitioners, geriatricians (consultants and specialist registrars), hospital nurses, and hospice nurses. RESULTS: When presented with an advance directive that applied to the same hypothetical scenario, health professionals came to divergent conclusions as to the "right thing to do." Arguments opposing treatment centred on the supremacy of autonomy as an ethical principle. Other arguments were that the decision to treat was consistent with the terms of the advance directive, or that, notwithstanding the advance directive, the patient's quality of life was sufficient to warrant treatment. CONCLUSION: Advance directives are open to widely varying interpretation. Some of this variability is related to the ambiguity of the directive's terminology whereas some is related to the willingness of health professionals to make subjective value judgments concerning quality of life.  (+info)

Respecting end-of-life treatment preferences. (5/32)

Most patients eventually must face the process of planning for their future medical care. However, few Americans have a living will or a durable power of attorney for health care. Although advance directives provide a legal basis for physicians to carry out treatment using a health care proxy or a living will, they also should reflect the patient's values and preferences. Family physicians are in a position to integrate medical knowledge, individual values, and cultural influences into end-of-life care. Family physicians can best respect the autonomy of patients by allowing the patient and family to prospectively identify relevant health care preferences, by sustaining an ongoing discussion about end-of-life preferences, and by abiding by the decisions their patients have made.  (+info)

Living wills and the Mental Capacity Act: a postal questionnaire survey of UK geriatricians. (6/32)

OBJECTIVE: To determine geriatricians' experience of and views on living wills, National Health Service Trusts' support of advance end-of-life health care planning and geriatricians' views on related legal changes in the Mental Capacity Act. DESIGN: Anonymous postal questionnaire survey of all 1,426 British Geriatrics Society members in England, Wales and Northern Ireland. RESULTS: A total of 842 (59%) questionnaires were returned. Of 811 geriatricians, 454 (56%) had cared for patients with living wills. Of the 280 who cared for patients when the living will had come into effect, 108 (39%) had changed treatment because of the living will and 84 (78%) of those felt that decisions had been easier to make. Living wills not already in effect made discussions with patients [171 of 178 (96%)] and families [135 of 178 (76%)] easier. Of 779 geriatricians, 713 (92%) saw advantages of older people using living wills; 467 of these also expressed concerns. Only 16 (2%) geriatricians who had concerns said that there were no advantages. A total of 214 (27%) were aware that their Trust had a form to help with discussions about cardiopulmonary resuscitation. Fewer [126 of 781 (16%)] were aware of a Trust policy on living wills. The proposal, in the Mental Capacity Bill, for advance refusals of treatment was supported by 59% (476 of 801), yet the proposal for a lasting power of attorney (LPA) covering health care was only supported by 47% (382 of 806). CONCLUSION: Many geriatricians have positive experiences of caring for patients with living wills. Despite recognising potential problems, most geriatricians support the use of living wills by older people. However, most believe that their Trust does not have a policy to support advance health care planning. Geriatricians have reservations about LPAs covering health care.  (+info)

Perioperative do-not-resuscitate orders--doing 'nothing' when 'something' can be done. (7/32)

Cardiopulmonary resuscitation (CPR) has the ability to reverse premature death. It can also prolong terminal illness, increase discomfort and consume enormous resources. Despite the desire to respect patient autonomy, there are many reasons why withholding CPR may be complicated in the perioperative setting. This review outlines these factors in order to offer practical suggestions and to provoke discussion among perioperative care providers. Although originally described for witnessed intraoperative arrests, closed chest cardiac massage quickly became universal practice, and a legal imperative in many hospitals. Concerns were raised by both health care workers and patient groups; this eventually led to the creation of the do-not-resuscitate (DNR) order. However, legal precedents and ethical interpretations dictated that patients were expected to receive full resuscitation unless there was explicit documentation to the contrary. In short, CPR became the only medical intervention that required an order to prevent it from being performed. Before the 1990s, patients routinely had pre-existing DNR orders suspended during the perioperative period. Several articles criticized this widespread practice, and the policy of 'required reconsideration' was proposed. Despite this, many practical issues have hindered widespread observance of DNR orders for surgical patients, including concerns related to the DNR order itself and difficulties related to the nature of the operating room environment. This review outlines the origins of the DNR order, and how it currently affects the patient presenting for surgery with a pre-existing DNR order. There are many obstacles yet to overcome, but several practical strategies exist to aid health care workers and patients alike.  (+info)

Content of advance directives for individuals with advanced dementia. (8/32)

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