Promoting Advance Directives
The administrators' role in encouraging advance directives.
By Hofmann, Paul B; Jennings, Bruce
November 24, 2005
Q. The Terri Schiavo case dramatized the
importance of having an advance directive that documents a persons
preferences regarding life-sustaining treatment options. Federal law now
requires healthcare organizations receiving Medicare and/or Medicaid
funds to ask patients at the time of their admission if they have an
advance directive and prohibits them from pressuring an individual into
completing one. And, while still complying with the law, should these
organizations be doing more to increase the proportion of all adults
with such documents?
A. Regardless of one's personal views of the
Schiavo case, one positive outcome was the tremendous growth in public
awareness about the value of discussing personal preferences concerning
end-of-life treatment options and designating a surrogate decision
maker. An opportunity now exists, but this interest will dwindle over
time unless a more aggressive and assertive campaign is mounted to
ensure mat advance directives are actually executed, placed in the
individual's medical record, and then honored by health professionals.
Background
Historically many hospitals have been hesitant to be
aggressive in promoting the completion of advance directives, including
documents described as durable powers of attorney for healthcare and
living wills. This passive role of hospitals was not necessarily due to
their traditionally conservative views of new social movements or being
risk averse to taking a high-profile position that might generate public
criticism. Instead, they have been very sensitive to the language of the
Patient Self Determination Act, the 1991 federal legislation requiring
organizations receiving federal funds to ask adult patients about the
existence of an advance directive. Healthcare organizations may not
discriminate against a person who does not complete an advance
directive; for example, the completion of advance directive forms cannot
be a condition of admission to a facility. In addition, employees are
explicitly prohibited from serving as witnesses if these documents are
completed within the organization.
These constraints were a prerequisite to Congressional
passage of the act at the time because, in part, they reflected the
ambivalence and ongoing controversy in America about forgoing
life-sustaining medical technology and allowing natural death. To
accommodate opponents of the legislation, ensuring the "neutral" role of
institutional providers was a vital concession. In the absence of such
neutrality, at least some legislators felt that hospitals, nursing
homes, and home health agencies might be viewed as having a hidden
agenda, one designed to force patients and their families to make hasty
and perhaps unwise decisions to limit life-sustaining treatment options.
Others were categorically opposed to any provision that would seem to
favor the right to forgo artificial nutrition and hydration, a form of
treatment that some regard as basic and ethically mandatory.
Greater Role by Healthcare Organizations
Society has paid a price for not recognizing the value
of advance directives. Since 1991, when less than one out of 10 adult
Americans had advance directives, there has been a gradual increase in
the perceived benefit of these documents. Even so, the total percentage
of Americans who have signed an advance directive remains very low.
Moreover, some studies have determined the presence of an advance
directive and even a do-not-resuscitate order in a medical record does
not guarantee that patients' preferences will be followed. Patients and
families need more positive incentives to make better use of them, and
physicians and other healthcare professionals need to comply with them
consistently.
The lay press and professional literature have made a
compelling case for completing advance directives. On a daily basis
throughout the country, patients, families, employees, and physicians
are severely compromised by the lack of clear and convincing evidence of
patient preferences regarding not only end-of-life decisions, but also
other medical decisions when patients temporarily lack decision-making
capacity.
A patient's values and preferences, when not
documented, are open to wide interpretation if the patient is unable to
participate in decisions affecting his or her treatment. The potential
for disagreement and conflict among family members and staff is much
higher under these circumstances. Among other problems, a lack of
consensus around a decision either to halt or continue treatment may
provoke allegations of insensitivity, generate feelings of guilt, create
increased stress, and produce threats of litigation.
Recommended Actions
How can healthcare organizations become more
aggressive in encouraging more people to have advance directives?
One step already taken by many health systems and
hospitals is to sponsor community forums and to collaborate with other
organizations that help educate citizens about advance directives.
Waiting to introduce the concept of an advance directive to a patient
who has never been exposed to its purpose until an elective
hospitalization causes unintended anxiety. Thus, there is wide agreement
that physicians should discuss advance directives with patients during
routine annual visits. Nonetheless, because healthcare organizations
have greater visibility, more resources, and a community education
responsibility, their leaders should be insisting that this topic be
highlighted in local forums, as well as in newsletters to staff,
volunteers, and residents in their service areas.
Since cultural and language barriers can undoubtedly
impede the completion of advance directives, special efforts must be
undertaken to help patients and families understand both why they exist
and to dispel any fears or misconceptions they may have about them.
Failure to do so is a sign of disrespect. Ethnic disparities in the
provision of healthcare services and their outcomes are irrefutable.
Failure to assist with advance planning and advance directives puts
patients at risk for futile, burdensome, expensive, and unwanted
treatment or, alternatively, denying these same individuals treatment
when it would be desirable.
Finally, executives should devote at least some of
their political leverage to this subject. Whether urging amendments to
the Patient Self-Determination Act or taking similar actions to
influence legislation and regulations at the federal and state levels,
healthcare leaders have an unprecedented opportunity to sustain the
public s awareness of these complex issues and to promote more informed
conversations around end-of-life treatment decision making.
(Note that you can create your Will, Power of Attorney and
Living Will online at
http://www.PartingWishes.com,
http://www.USLegalWills.com and
http://www.LegalWills.ca).
For More Information Contact:
PartingWishes.com
Email:
support@partingwishes.com
Internet:
http://www.partingwishes.com
