Medical Directives Research Articles

Advance care planning and the ethical obligation of death literacy as a public health initiative in India.

This article highlights the importance of advance care planning (ACP) in good end-of-life care (EOLC). The judgement by the Supreme Court of India legalised Advance Medical Directives in 2018 and in January 2023, amended the procedure to make it easier. The article describes the advantages of ACP, the numerous ethical dilemmas at the end of life that it seeks to address and avoid, the latest legal procedure, the barriers, the need for awareness among healthcare providers, legal professionals as well as the public, and the need for legislation to translate the law into action. Educating citizens about their right to choose the kind of care they want at the end of life, including the right to refuse treatment, is the moral and ethical duty of all health professionals. Making death literacy and ACP a part of a public health initiative would be a major step towards meeting the obligations reflected in the World Health Organization guidelines and National Health Policy 2017, which envisage palliative care and EOLC as an integral part of Universal Health Coverage, requiring support from the government as well as the participation of civil society.

"What you Say Matters": Review of Clinical Outcome of Advanced Medical Directives Between Cancer and Non-cancer Patients in a Chinese Culture Society.

Advance medical directives (AMD) are statements made by individuals indicating the life-sustaining treatment that they would refuse in the future when they lost their mental capacity for medical decisions. While the proposal for the AMD legislation is ongoing locally in Hong Kong SAR, there are limited reviews on the clinical outcomes associated with it. To provide a comprehensive review on clinical outcomes of signed AMD. Retrospective, multi-center study, which includes AMD signed within five cluster hospitals. Records of signed AMD from 1st JAN 2020 to 31st DEC 2022 were retrieved from a central registry. Clinical information of each patient was obtained from the electronic patient record. 456 patients with documented AMD were included in the study. 91.6% of AMD were signed by palliative care (PC) team. Majority (74.6%) of the patients were accompanied by family members or friends when AMD were signed. The concordance rate between the AMD and the medical care received was 89.5%. No patient revoked their AMD. Cancer and non-cancer patients showed similar rates of AMD concordance, frequency of Accident & Emergency Department (AED) visits or acute ward admissions, duration of hospital stays in the 30days before death, and prevalence of receiving invasive or intensive treatments. Our study demonstrated that PC team currently plays a pivotal role in AMD completion, and AMD remains important in ensuring patients' care preferences are executed across different medical conditions. With the upcoming AMD legislation in Hong Kong SAR, adequate promotion and education should be launched.

웰다잉 인식, 윤리적 민감성, 사전연명의료의향서 지식 및 태도: 간호대학생을 중심으로

웰다잉 인식, 윤리적 민감성, 사전연명의료의향서 지식 및 태도: 간호대학생을 중심으로

Are Advance Medical Directives Legal in India?

MEDICOLEGAL

End-of-life decision-making in the emergency department and intensive care unit: Health professionals' perspectives on and knowledge of the law in Queensland.

To investigate ED and intensive care unit healthcare professionals' perspectives and knowledge of the law that underpins end-of-life decision-making in Queensland, Australia. An online survey with questions about perspectives, perceived, and actual, knowledge of the law was distributed by the professional organisations of medical practitioners, nurses and social workers who work in Queensland EDs and intensive care units. The survey responses of 126 healthcare professionals were included in the final analysis. Most respondents agreed that the law was relevant to end-of-life decision-making, but that clinician and family consensus mattered more than following the law. Generally, doctors' legal knowledge was higher than nurses'; however, there were significant gaps in the knowledge of all respondents about the operation of advance health directives in Queensland. The legal framework that supports end-of-life decision-making for adults who lack decision-making capacity has been in place for more than two decades. Despite frequently being involved in making or enacting these decisions, gaps in the legal knowledge of healthcare professionals who work in EDs and intensive care units in Queensland are evident. Further research to better understand how to improve knowledge and application of the law is warranted.

Awareness of Do Not Resuscitate (DNR) Order among Medical Students in Universiti Sains Malaysia

Introduction: Do Not Resuscitate (DNR) order is a type of Advance Medical Directive (AMD) that documents a patient’s wishes or desire to refrain from Cardiopulmonary Resuscitation (CPR), especially in the terminally ill patient. It is a sensitive issue in patient care and less is known on medical students awareness on the area. Aim: This study assessed the opinion, knowledge, awareness and familiarity toward Do Not Resuscitate (DNR) order among undergraduate medical students from year 1 to 5 in Universiti Sains Malaysia. Methods: A cross-sectional study was conducted with 250 undergraduate medical students using an online questionnaire on awareness towards DNR orders. Descriptive statistics, independent t-test and one-way ANOVA were applied to examine the distribution and association of DNR awareness among medical students with year of study, gender, race and religion. Results: The study indicated that most participants (84.4%) were familiar with DNR orders. There was no significant association between all 4 variables (year of study, gender, race and religion) with level of awareness among undergraduate medical students in HUSM. Conclusion: Undergraduate medical students have a good awareness on DNR orders. Despite having a multiracial and multi religion community, the medical students have similar patterns in their knowledge about DNR.

315 Financial planning as part of an integrated care comprehensive geriatric assessment

Abstract Background Evaluation of a social support network, including the need for support in managing finances independently is an essential component of Comprehensive Geriatric Assessment (CGA). Safeguarding of finances (e.g. third party authorities, enduring power of attorney, will) should be encouraged in all order adults, particularly those with cognitive decline to provide security and protection of their wishes should they lose capacity to manage financial decisions. We sought to evaluate financial competency and preparedness in a population attending our Integrated Care for Older Persons (ICPOP) service. Methods Participants included were new patients referred to ICPOP between January and May 2023 with completed CGAs. A retrospective analysis was conducted of patient demographics, ability to independently manage finances, dependency on personal and instrumental activities of daily living. Results Of our analytic cohort (n = 85), 56% (n = 48) were female, median age was 81. The most common reason for referral was new change in cognition which accounted for 48% (n = 41/85) of patients. Median Rockwood Clinical Frailty Scale was 5. Median Barthel score was 17. Median Lawton-Brody score was 4/8 with 80% (n = 68) patients scoring 1 in the financial section which indicates their ability to manage their finances partially or completely. 60% (n = 51) of patients collected their own pensions and on specific questioning reported managing their finances independently. No patient had an advanced care directive, 90% (n = 77/85) did not have EPoA and 41% (n = 35/85) did not have a will. Conclusion We identified that in those attending our service, very few had EPoA in place with no person having a documented advanced care directive. Over half required some if not total assistance with financial matters. Supported decision making is essential to uphold the right of the older person to make choices on their welfare, property and affairs and CGA provides opportunity for intervention in this remit.

Advance Care Planning in India: Current status and future directions. A short narrative review

India is undergoing economic, demographic and epidemiologic transitions. The healthcare industry is expanding rapidly as the burden of non-communicable diseases increases. The Indian Supreme Court [1] has recently enabled Advance Medical Directives (AMD). Implementation of Advance Care Planning (ACP) will depend on civil society and the palliative care sector until government support is available.

좋은 죽음을 위한 사전연명의료의향서 작성에 관한 비판적 고찰

좋은 죽음을 위한 사전연명의료의향서 작성에 관한 비판적 고찰

Gaze behavior as a visual cue to animacy.

A characteristic that distinguishes biological agents from inanimate objects is that the former can have a direction of attention. While it is natural to associate a person's direction of attention with the appearance of their face, attentional behaviors are also a kind of relational motion, in which an entity rotates a specific axis of its form in relation to an independent feature of its environment. Here, we investigated the role of gaze-like motion in providing a visual cue to animacy independent of the human form. We generated animations in which the rotation of a geometric object (the agent) was dependent on the movement of a target. Participants made judgements about how creature-like the objects appeared, which were highly sensitive to the correspondence between objects over and above their individual motion. We varied the dependence between agent rotation and target motion in terms of temporal synchrony, temporal order, cross-correlation, and trajectory complexity. These affected perceptions of animacy to differing extents. When the behavior of the agent was driven by a model of predictive tracking with a sensory sampling delay, perceived animacy was broadly tuned across changes in rotational behavior induced by the sampling delay of the agent. Overall, the tracking relationship provides a salient cue to animacy independent of biological form, provided that temporal synchrony between objects is within a certain range. This motion relationship may be one to which the visual system is highly attuned, due to its association with attentional behavior and the presence of other minds in our environment. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The prevalence and types of advance care planning use in patients with advanced cancer: A retrospective single-centre perspective, Australia

Objectives: In Australia participation rate in Advance Care Directives is 14%, and research is limited on Advance Care Planning (ACP) invitations and uptake among the patients with advanced cancer (PwAC). This study identifies the prevalence and types of documented ACP discussions in PwAC who died within two or four weeks of receiving chemotherapy. Design: A retrospective audit was conducted. Statistical analysis was calculated in SPSS. Difference in ACP invitation and utilization between three groups [control, <2-weeks, and –4 weeks] was measured by Kruskal–Wallis and Chi-square (or Fisher-Exact) tests. Post-hoc follow-up pair-wise comparisons were performed. Adjusted prevalence ratios were estimated using two logistic regression models. Setting: This study was conducted in XXX Coast University Hospital, Australia. Participants: The records of 339 patients were examined and 320 patients were found eligible. Results: Of the 320 PwAC [male: 55%; median age: 65 years], 227 (71%) received ACP invitation, and among the invited patients, 89% used Acute Resuscitation Plan; 54% used Enduring Power-of-Attorney; and 20% completed Advance Health Directives. From 7.5% [n = 24] of the patients who received chemotherapy in their last 2-weeks of life, 42% had not received an ACP invitation, 29% didn’t have Acute Resuscitation Plan and only 4% completed Advance Health Directives. There were significant differences among Control, <2-weeks, and 2–4 weeks groups in completing Acute Resuscitation Plan (P = 0.003) and Advance Health Directives (P = 0.045). A significant difference was also observed between control and <2-weeks groups in number of days since Acute Resuscitation Plan used. Completing an Acute Resuscitation Plan was associated with a lower risk of dying within two-weeks of chemotherapy (OR = 0.246; P = 0.008). Conclusions: Low rates of ACP invitation and use in PwAC, especially who received chemotherapy in 2-weeks of dying confirm a need for embedding and regularly revisiting ACP framework in cancer care and educating staff, patients, and their family caregivers to increase uptake.

The Role of Physicians in Endorsing Advance Medical Directives

Physicians have a fiduciary duty to educate patients regarding all options available for end-of-life medical care as patients, physicians, and families explore together the patients’ wishes for end-of-life treatment.

Potentially avoidable emergency department transfers from residential aged care facilities for possible post-fall intracranial injury.

To determine the percentage of potentially preventable residential aged care facility (RACF) to ED transfers for potential intracranial injury post-fall. To describe rates of CT brain (CTB) performance, intracranial trauma-related findings, neurosurgical intervention, and patient outcome. Patient lists were obtained from the hospital electronic medical record, screened for eligibility and data abstracted. Potentially preventable was defined as: (1) RACF return from ED within 24 h, regardless of CTB performance or finding; (2) ED management could reasonably have been provided at the RACF. Comparisons between those with CTB performed or not, including external signs of craniofacial trauma, anticoagulant medication use, baseline cognitive impairment and presence of an advanced care directive (ACD) were made. Of 784 patients, 415 (53%) were classified as potentially avoidable. Of these, 314 (76%) had a CTB. Of all 784 patients, 538 (69%) had a CTB performed. CTB was more likely with presence of external signs of craniofacial trauma (26% [95% CI 23-30] vs 20% [95% CI 15-25], P < 0.001) and anticoagulant use (59% [95% CI 55-63] vs 42% [95% CI 37-49], P < 0.001) but not for presence of cognitive impairment or ACD. From the 538 CTBs, 31 (6%) patients had acute intracranial trauma-related findings with all having conservative management. None of the 11 (1%) deaths were in the potentially preventable subgroup. Just over half of the RACF to ED transfers were classified as 'potentially avoidable'.

Prevalence and factors associated with advance health directives in frail older inpatients

Advance health directives (AHD) can be used to explore and document patient preferences for treatment and are therefore an important aspect of care planning. To investigate the prevalence and factors associated with AHD among older inpatients. This retrospective study included 6449 patients, aged ≥65 years referred for specialist geriatric consultation between 2007 and 2018 in Queensland, Australia. The interRAI-Acute Care Comprehensive Geriatric Assessment tool was used to calculate a frailty index (FI), range 0-1, based on 52 possible deficits, and categorised into intervals of 0.1 for analysis. FI was also grouped according to previously reported cut points: fit (FI ≤0.25), moderately frail (FI >0.25-0.4), frail (FI >0.4-0.6) and severely frail (FI >0.6). An AHD was present in 1032 (16.0%) of 6449 patients. Those with an AHD were significantly frailer than those without an AHD (mean FI 0.52 vs 0.45; P < 0.001). Higher frailty (odds ratio (OR): 1.34 (1.27-1.40)), older age (OR: 1.04 (1.03-1.05)), living in an institution (OR: 1.33 (1.01-1.73)) and recent hospitalisation (OR: 1.42 (1.23-1.62)) were significantly associated with higher prevalence of AHD. Prevalence of AHD increased over time, from 7.6% (n = 66) in 2008 to 35.4% (n = 99) in 2017. The presence of AHD is associated with sociodemographic factors, as well as higher frailty levels. Prevalence of AHD among inpatients has increased over the past decade but remains modest.

Advanced medical directives or written living wills among saudi intensive care units, current practice and need to optimization: Opinion of trainees

Background: Ethical dilemmas are mostly developed in critically ill patients near the end of life. The point where the treating physician decides to withhold the intensive medical support represents a daily challenge on the current intensive care medicine. Considering patients' wishes in near-death events and their vision, through writing an advance medical directive (also known as Living Will), was introduced early in the developed western countries. On the other hand, it is not easy to talk about near-death events in many other regions of the world, mainly because of cultural and religious differences. Objectives: The study aimed to explore the current practice regarding near-death events in one of the Middle Eastern countries, particularly in Saudi Arabia. The main objectives of this study were measuring the involvement of patient's wishes in near-death medical decisions and analyzing the need and usefulness of encouraging the practice of writing advance medical directives in this demographic area. Methods: The data were obtained from a group of Saudi intensivists, who are dealing the most among other groups of physicians with near-death events, almost daily. They were affiliated with ten hospitals or intensive care units in Saudi Arabia. Data were collected during the period from March 2018 to July 2018. It was done based on participants' knowledge. Due to the low response rate, data were analyzed using descriptive statistics only. Results: A total of 51 physicians working in different intensive medical care units had responded to our survey. About 88% of them were male, 47% aged between 31 and 40 years of age; with different levels of experience (45% were residents, 35% worked as a senior registrars and 20% were consultants' intensivists). Although in Saudi Arabia, a (living will) be not considered legal writing, 31.35% of the respondents had seen many cases where patients openly discussed their near-death wishes with the family members. From the respondents, 84.31% believed that a living will tend to help in their decision-making, and 92.16% considered living wills helpful in making the final call regarding withholding/withdrawing the treatment. According to 72.55% of them, the presence of living wills would help in decreasing the near-death anxiety and depression among family members of a deceased patient and tend to help ease out the situation as they consider it as a final wish of the patient. Conclusion: It is concluded that the patient's wishes are essential in making an end-of-life decision; they should be represented by the patient and should also be respected by the clinical staff. However, more studies needed to explore the willingness of the general population in this culture to express their wishes and the best method to elicit these wishes should be sought, with respect to the cultural and religious beliefs and differences.

간호대학생의 사전연명의료의향서 태도에 미치는 영향

The purpose of this study was to identify the influence factors on the attitude of the advance medical directives by identifying the knowledge, attitude about advanced medical directives and biomedical ethics awareness among nursing students. The study was conducted using descriptive survey, among 193 nursing students from June 14 to 30, 2021. Responses were analyzed using SPSS WIN 25.0. Students’ knowledge, attitudes of the advance medical directives and biomedical ethics awareness were measured using a structured self-report questionnaires. Influencing factors emerged in the order of knowledge, biomedical ethics awareness, and legal knowledge on life-sustaining care advanced medical directives with an explanatory power of 38.1%. The results of this study provide basic data for developing an educational program to increase the knowledge of advance directives on life-sustaining health care and biomedical ethics awareness in order to cultivate attitudes toward advanced life-sustaining medical care among nursing students.

Prospect and Legal Challenges of Medical Tourism in Relation to the Advance Medical Directive (AMD) in Malaysia

People fly for several reasons. One of the goals is to obtain medical attention. This idea is known as “medical tourism.” In defending this concept, the notion of medical tourism is one of the prospects of increasing industries that have rapidly grown in Malaysia and other countries. One of the factors that led to this trend is the propensity to pursue better medical care at a lower cost. Around the same time, certain patients in modern society have begun to provide input on their medical care in cases where they are unable to give consent. Advance Medical Directive (AMD) is a particular directive containing the desires of a knowledgeable patient regarding his or her future medical plans if he or she becomes incompetent or unable to make any decisions regarding his or her body. However, the concern that arises in the sense of medical tourism is whether there are applicable laws in Malaysia that will ensure that the AMD of patients is enforced. The art of AMD is still relatively new in the country and, as a result, the legal status on the AMD is still vague and uncertain. The purpose of this article is, therefore, to define the laws that can be applied in relation to AMD in the context of medical tourism. The approach used in this article is qualitative. It found that Malaysia did not have a clear legal framework for AMD within the scope of medical tourism. This article concludes that this legal challenge can be overcome by means of the special AMD regulations on medical tourism in Malaysia.

Honouring Wishes of Patients: An Islamic View on the Implementation of the Advance Medical Directive in Malaysia.

An Advance Medical Directive (AMD) is a document in which competent patients express their wishes regarding their preferred choice of future medical plans in the event they become incompetent. AMD is important in relation to the patient’s right to refuse treatment. However, they must also consider cultural and religious values of different communities. In Islam, there are several concerns that need to be addressed, namely the validity of the AMD according to Islamic jurisprudence and patients’ right to end-of-life decision-making. To address these concerns, this article refers to multiple sources of Islamic jurisprudence, such as the Quran, the tradition of Prophet Muhammad and the works of Islamic scholars related to this topic. Based on the findings, Islam does not forbid the use of AMD as a method to honour patients’ wishes in their end-of-life care. Islamic jurisprudence emphasises on the importance of seeking patients’ consent before carrying out any medical procedures. However, several conditions need to be given due attention, such as: i) a patient’s cognitive capacity during the process of drawing up an AMD; ii) the professional views of medical experts; iii) the involvement of family members in end-of-life care and iv) the limitations of a patient’s decision-making in creating an AMD.

Factors Influencing Health Department Students’ Attitudes towards Advance Medical Directives

Factors Influencing Health Department Students’ Attitudes towards Advance Medical Directives

Dying Wishes: Understanding Advance Medical Directives from the Malaysian and Islamic Law Perspectives

The respect for patient autonomy is a bioethical principle that has acquired a compelling degree of prevalence in modern medical practice. While a doctor is ethically and lawfully bound to respect a patient’s preference and personal values in administering the requisite treatment, the duty to do so is more intricate in end-of-life care, when most patients are unable to partake in the decision-making process. An advance medical directive thus provides an assurance that the patient’s right to make autonomous decisions is preserved and will not be defeated by any future incapacity. It also serves to alleviate the ethical dilemma faced by doctors and assist them to determine the course of treatment according to the incompetent patient’s wishes. In turn, this facilitates healthcare providers to effectuate a more functional allocation of resources, which include costly life-sustaining equipment. In Malaysia, although advance care planning and advance medical directives are fairly novel concepts, there have been recent calls by certain sectors to increase awareness among the public and incorporate such measures into the delivery of healthcare services. This paper seeks to discuss the viability of integrating advance medical directives into the Malaysian regulatory framework on the provision of healthcare. Accordingly, this will also include deliberation on the Islamic standpoint with regard to the subject matter, in view of Malaysia’s religious demography and the position of Islam as the official religion of the country.