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advance directives

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. [13] It is an umbrella term that includes living will & health care proxy. [9] 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: 1) discussion between patients & physicians infrequently held - advance directives sometimes viewed as a substitute for goals of care [12] 2) most discussion focus on interventions, rather than outcomes & willingness to take risks 3) patients misunderstand the outcomes of life-sustaining treatments 4) goals of care are too frequently not transferred across care settings 5) 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 [9] * 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 [5] - advance directives documented in a minority of patients after ischemic stroke [7] - written advance directives more common among dominant North American culture than in minority groups [9] - 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 [14]

Related

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

Specific

code status durable power of attorney (DPoA) living will

References

  1. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 582
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 17 American College of Physicians, Philadelphia 1998, 2006, 2015
  3. Rosenfeld K. In: Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
  4. Rosenfeld K. In: Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 25-28, 2002
  5. Zaros MC et al. Opportunity lost: End-of-life discussions in cancer patients who die in the hospital. J Hosp Med 2013 Jun; 8:334. PMID: 23169553
  6. Castillo LS, Williams BA, Hooper SM et al Lost in translation: the unintended consequences of advance directive law on clinical care. Ann Intern Med. 2011 Jan 18;154(2):121-8. PMID: 21242368
  7. Robinson MT, Vickrey BG, Holloway RG et al The lack of documentation of preferences in a cohort of adults who died after ischemic stroke. Neurology. 2016 May 31;86(22):2056-62. PMID: 27060165
  8. NEJM Catalyst. (Video) Helping Patients Complete Advance Directives. http://catalyst.nejm.org/videos/helping-patients-complete-advance-directives/
  9. Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016 - Geriatric Review Syllabus, 10th edition (GRS10) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2019 - Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022
  10. Rolnick JS, Asch DA, Halpern SD. Delegalizing Advance Directives - Facilitating Advance Care Planning. N Engl J Med 2017; 376:2105-2107. June 1, 2017 PMID: 28564570 http://www.nejm.org/doi/full/10.1056/NEJMp1700502
  11. Gaster B, Larson EB, Curtis JR. Advance Directives for Dementia. Meeting a Unique Challenge. JAMA. Published online November 6, 2017. PMID: 29114779 https://jamanetwork.com/journals/jama/fullarticle/2662678
  12. Auriemma CL et al. How traditional advance directives undermine advance care planning: If you have it in writing, you do not have to worry about it. JAMA Intern Med 2022 Apr 25; [e-pub]. PMID: 35467697 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2791668
  13. Vogelstein E Autonomy and the Moral Authority of Advance Directives. J Med Philos. 2016 Oct;41(5):500-20 PMID: 27465774
  14. Wong SPY et al. Value placed on comfort vs life prolongation among patients treated with maintenance dialysis. JAMA Intern Med 2023 Mar 27; [e-pub] PMID: 36972031 PMCID: PMC10043804 Free PMC article https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2802800