Durable Power Of Attorney Research Articles

Selected Ethical Issues in Aging: A Practical Perspective

Every day, health care providers in surgical and hospital settings face ethical issues with patients who require medical intervention. Since no one ever knows when he or she might become a patient who has lost the ability to communicate intent caused by an injury or disease, it is important to plan ahead and appoint an agent through a medical durable power of attorney to communicate wishes regarding care. An agent or other surrogate decision-maker often faces very difficult issues when the patient's medical status may mean that he/she is reaching the end of his or her life. Care decisions require a working knowledge of the medical issues and the application of ethical values, along with a process for coping with the emotional issues. Developing options and making medical decisions involves a blend of precise clinical information and the personal style and philosophy of the patient and the principles of clinical ethics.

Schiavo Case Still Triggers Review of Ethics

Schiavo Case Still Triggers Review of Ethics

Swing Low, Sweet Chariot: Abandoning the Disinterested Witness Requirement for Advance Directives

Advances in medical technology over the past several decades have made it possible to increase life long past the point where many patients would otherwise suffer a natural death. In the past, the most common causes of death were abrupt killers such as tuberculosis, pneumonia, and injuries. Now the average American can expect to spend the final two years of life too disabled to perform even the routine activities of life unassisted. Thousands of people also languish in irreversible comas or persistent vegetative states due to illness or injury. Meanwhile, the ranks of the elderly can be expected to burgeon as Baby Boomers approach retirement age and the number of people treated with life support technology (alternatively described as “life-preserving” and “death-prolonging”) will rise accordingly. The conventional wisdom is that most people would like to avoid such treatment, preferring to die with dignity. Advance directives ostensibly enable people to avoid this fate, by expressing their treatment decisions in advance (a “living will”), or by designating someone they trust to make treatment decisions for them (a “durable power of attorney for health care”).

End-of-life issues for a modern India - Lessons learnt in the West

Consideration of end-of-life issues is a relatively new phenomenon in the Indian context. It is difficult to assess the magnitude of the problem except the certainty that these issues will affect more patients and their families in the future. The approaches used in the West to prepare patients and public in general such as living will and durable power of attorney have not always been useful. The religious and social attitudes have an effect on facing end-of-life issues and yet these attitudes are in transition. The lack of education in bioethics and paucity of case law is reviewed. New approaches to the end-of-life issues in the light of experience gained in the West are suggested.

Information for Rehabilitation Counselors on Guardianship and Alternatives to Guardianship for Persons with Traumatic Brain Injuries

As the number of persons with traumatic brain injury has increased in the United States, the focus placed on whether or not guardianship is appropriate for such individuals has expanded. The purpose of this paper is to provide knowledge for rehabilitation counselors on the issues of guardianship and to explore other, less intrusive methods to meet the needs of individuals with traumatic brain injuries while maximizing their independence. Issues such as competency and independence need to be addressed in order to determine the necessity of guardianship. The level of restriction that guardianship imposes on the individual must also be considered in regards to what is most appropriate for the person with a traumatic brain injury, with consideration given to alternatives to guardianship that are less restrictive and invasive. Alternatives to guardianship include designating a representative payee, choosing a durable power of attorney, or creating a trust for the person with a traumatic brain injury. Rehabilitation counselors should be knowledgeable of the issues surrounding guardianship and alternatives to guardianship in order to have a strong knowledge base regarding issues that may affect their clients with traumatic brain injuries and to be able to provide the highest quality of services to their clients.

Advance Directives among Elderly Veterans

The goal of this study was to identify various sociodemographic and clinical variables related to the completion of advance directives among 281 elderly male veterans recruited from the acute medical inpatient unit of a Veterans Affairs Medical Center. Results found the rates of advance directives to be higher among elderly male veterans compared to other populations (44% had either a durable power of attorney or a living will, 34.2% had a living will, and 35.2% had a durable power of attorney). In addition, individuals who completed an advance directive were significantly more likely to be Caucasian than non-Caucasian. Other than race, there were other important factors including religiosity, desire for life-saving treatment, social support, and depressive symptoms that were related to the completion of advance directives among elderly veterans. Such factors seem consistent with the research literature on nonveteran populations.

Surrogate decision-making and related issues.

This article discusses the role of surrogate decision-makers for persons who are cognitively impaired and cannot give informed consent. Questions raised follow. Is surrogate consent in research analogous to proxy consent in health care? What are some issues in surrogate consent? How does the risk-benefit ratio affect the consent process? What are the investigator's responsibilities regarding surrogate consent? Issues discussed include advance directives, durable power of attorney, legally authorized representatives, substituted judgment, double informed consent, responsibilities of surrogates, and barriers to informed consent. The article ends with recommendations to clarify state and national laws, change research designs, and establish a national mechanism for reviewing promising research that is usually prohibited.

Another matter of life and death: what every anesthesiologist should know about the ethical, legal, and policy implications of the non-heart-beating cadaver organ donor.

Summary It remains to be seen whether the use of NHBCDs willsignificantly increase the number of organs available fortransplantation. Organ retrieval from such donors maybe ethical, provided that conflicts of interest amonghealthcare providers are defined and prevented, the ex-ploitation of vulnerable persons is avoided, the with-drawal of care is in accordance with accepted and ap-propriate medical standards, the inadvertent harvestingof vital organs from living patients does not occur, andthe humane treatment of dying patients and their fami-lies is safeguarded. Further, the process must not beimplemented in ways that cause distrust among dyingpatients that their medical and social needs will be putsecondary to those of patients needing transplantableorgans. It is arguable whether any existing protocolcompletely addresses all of these issues.Any anesthesiologist involved with either policies orcare of patients who will become NHBCDs should beeducated about the legal, ethical, and medical issuesinvolved and should not undertake such duties withoutadequate knowledge and training. Even when with-drawal of care is anticipated in an operating room set-ting, only physicians with appropriate knowledge, train-ing, and experience in the withdrawal of life support andcomfort care of the dying patient should be involvedwith the NHBCD. Such specialty expertise is not withinthe customary training and practice of most anesthesiol-ogists. The physician withdrawing life support should besomeone who has been involved with the patient andfamily throughout the decision-making process, so thatdeath does not become, as Renee Fox described it, a“desolate, profanely ‘high-tech’ death that the patientdies, beneath operating room lights, amid masked,gowned, and gloved strangers.”

How physicians approach advance care planning in patients with mild to moderate Alzheimer's disease.

Decision-making ability regarding end-of-life issues is often compromised by dementia in patients with Alzheimer's disease. This study assessed physicians' discussions of advance care planning with patients with mild to moderate Alzheimer's disease. Data were collected by a survey of full-time faculty in the departments of Medicine and Family Medicine and the Center for Aging at the University of Medicine and Dentistry of New Jersey-School of Osteopathic Medicine, as well as physicians in private practice affiliated with the Kennedy Health System. Data consisted of questions that assessed whether advance care planning was provided, what specific topics were discussed, and what actions were taken if advance care planning was not offered. Of the 271 physicians to whom the survey was sent, 63 responded, for a return rate of 23%. Of those responding, 81% indicated that they counseled their patients regarding advance care planning issues, while 19% did not. Of those who provided advance care planning for their patients (N = 51), 88% discussed living wills; 53%, the durable power of attorney for healthcare; 47%, end-of-life care; and 35%, financial planning issues. Thirty-seven percent recommended an elder law attorney, and 31% made a referral to the Alzheimer's Association. Of those who provided advance care planning for their patients' caregivers (N = 51), 86% discussed living wills; 78%, nursing home care; 69%, driving issues; and 47%, end-of-life care. Twenty-five percent referred their patients to an elder law attorney. Results indicate that physicians need to be more knowledgeable and proactive in their approaches to advance care planning for patients with mild to moderate Alzheimer's disease.

The impact of a palliative medicine consultation service in medical oncology.

This prospective study of consecutive patients describes the palliative medicine consult service in a tertiary level cancer center and its impact on patient care. All inpatients/outpatients referred to the Palliative Medicine Program in a 4-month period were enrolled. Data were collected at the initial consultation using standardized forms with spaces for: reason for the consultation, referring service, demographics and history, ECOG performance status, symptoms, prognosis and diagnostic tests, treatment, and care plan. In all, 240 patients were seen: 79% were referred for symptom management; 53% were referred from medical oncology; and 50% were women. Median patient age was 67 years (range 18-96). Median performance status was 2 (1-4). Most (84%) of the patients had cancer. The cancer sites were: lung in 26% of cases, colorectal in 8%, and breast in 7%. Inpatients accounted for 53% and outpatients, for 47% of the study population. The median number of symptoms per patient was 13 (2-30). The estimated survival was <2 weeks in 15%, 2-8 weeks in 38%, 2-6 months in 37%, and >6 months in 10%. The patients' goals were: improve symptoms for 84%, return home for 55%, and no further admissions for 5%. The support systems named by patients were: family in 89%, friends in 13%, and the community in 5%. Hospice care was discussed at the consultation with 38% of the patients, would have been inappropriate for 31%, was not discussed with 22%, and had been discussed before with 9%. In response to questions about psychosocial care, a caregiver was identified by 78%, a spokesperson by 75%, and durable power of attorney was referred to by 21%. The DNR status was discussed on consult by 57%, had already been discussed with 30%, and was not discussed with 13%. Plan of care foresaw outpatient follow-up for 40%, inpatient follow-up for 32%, and transfer to palliative medicine for 27%. In 39% of cases the consults were considered late referrals. New medications suggested were opioids for 46% of patients, antiemetics for 28%, a bowel regimen for 24%, steroids for 15%, and others for 51%. (1) Palliative medicine consultation involves common complex medical, psychological, and social problems. (2) Complex symptomatology in this population is confirmed. (3) Multiple interventions were suggested even at the initial consultation. (4) Important issues such as DNR (do not resuscitate) status, support system, treatment goals, and eligibility for hospice care had often not been addressed.

Reconsidering surrogate decision making: Aristotelianism and Confucianism on ideal human relations.

Recent decades have witnessed the rapid development of surrogate decision making in clinical medicine in Western countries, especially the United States. 1 Various advance-care documents such as ‘‘living wills,’’ ‘‘advance directives,’’ and ‘‘durable power of attorney’’ have been accepted in law and have become frequently used in hospitals. Increasingly patients come to adopt such documents to designate other persons as their surrogate decision makers in the event that the patients become incompetent. A surrogate decision maker (or proxy) is designated to make medical decisions for the patient in accordance with the patient’s previously expressed wishes. Thus, only a person who is familiar with the patient’s own values and expectations and is willing to follow them should be appointed surrogate decision maker. In practice, it is usually either family members or friends who are appointed to be proxies. No doubt this practice has arisen against the background of increased life expectancy, made possible primarily by progress in medical science and technology. Almost all societies today are experiencing an increase in the number of aged members in their population. 2 Among the elderly with chronic diseases, reduced competence often accompanies dementia or other cognitive disorders. As a result, there is a growing need to provide for making surrogate health-care decisions for incompetent elderly patients who in the past would have died before reaching this condition. However, it would be misleading to see the rise of this recent Western pattern of surrogate decision making as necessarily a result of an increase in the number of elderly with declining competence. This increase certainly necessitates a concomitant increase in surrogate decision making in clinical practice. But this need should not be seen as the sole determinant of the norms regarding who is to be appointed surrogate as well as the way in which surrogate decisions are made. There must be other, broader and deeper cultural as well as scientific and technological factors underlying the particular method by which surrogates are designated and decisions made in Western society. It is my view that the pattern of surrogate decision making in any society is determined first and foremost by the dominant perspective on human life and relations that is accepted by that society. The current American model of surrogate decision making, in my view, is best seen as a manifestation of the dominant overall Western perspective on human life and relations as it relates to current medical practice.

Ethical Issues in the Long-Term Management of Progressive Degenerative Neuromuscular Diseases

Degenerative neuromuscular diseases are characterized by a gradual decline of motor function leading to respiratory collapse, while the patients retain consciousness and cognition. The ethical challenges of caring for such patients result from the need to implement various combinations of initiating, withholding, and withdrawing life-sustaining interventions. In caring for this population of patients physicians should adhere to the ethical principles of autonomy, beneficence, nonmaleficence, and justice. A central goal of care is to avoid a decisional impasse by anticipating end-of-life issues in discussion with patients and families. The evolution of these diseases is usually slow enough to allow ample patient education, and thus physicians should foster early and frank discussions and encourage the patient to set up advance directives, designate a durable power of attorney for health care, and plan end-of-life care. Competent patients have the right to accept or refuse life-sustaining therapies, and such requests should be honored. In delivering palliative care, adequate sedation and analgesia must be provided when needed. If a decision to withhold or withdraw life support is made, patient comfort and dignity are the ultimate objectives.

Durable Power of Attorney for Health Care and Living Wills: What Nurses Need to Know

Durable Power of Attorney for Health Care and Living Wills: What Nurses Need to Know

The consent process for cadaveric organ procurement: how does it work? How can it be improved?

Understanding the consent process that organ procurement organizations (OPOs) use is crucial to improving the process and thereby reducing the number of individuals who die each year for want of an organ transplant. However, no data exist on OPOs' current consent practices. To assess whose wishes OPOs follow when procuring solid organs from deceased individuals and whether advance directives and computerized registries might improve the consent process for solid organ procurement. Telephone survey conducted from June to August 1999 of all 61 active OPOs. Responses to the 49-question survey addressing consent practices in specific scenarios of deceased and next of kin wishes. Widespread divergence exists in OPOs' consent practices for cadaveric solid organ procurement. Regarding overall consent practices, 19 (31%) OPOs reported that they follow the deceased's wishes, 19 (31%) follow the next of kin's wishes, 13 (21%) procure organs if neither party objects, 8 (13%) procure organs if either party consents or neither objects, and 2 (3%) do not follow any of these 4 overall practices. These differences appear to be traceable to implicit ethical disagreements about whose wishes should be followed. A total of 29 (48%) OPOs reported having an official policy to address whether they follow the family's or deceased's wishes. Regarding factors that influence OPOs' choice of consent practice, 29 (48%) respondents ranked impact on the deceased's family as the most important factor, 13 (21%) ranked state law as most important, and 7 (11%) ranked the priority of the deceased's wishes as most important. Durable power of attorney appeared to have substantial weight in OPOs' decisions; for example, in the scenario in which the deceased supported organ donation and the next of kin opposed it, 34 (56%) OPOs reported they were likely to procure organs based on the consent of the holder of the deceased's durable power of attorney, whereas only 7 (11%) reported they were likely to procure organs based on a document of gift (a living will, donor card, or driver's license). Expanding the legal scope of living wills to cover individuals' organ donation preferences would likely have little impact on procurement rates. In contrast, expanding the legal scope of durable powers of attorney for health care may have a significant impact. A national discussion should take place addressing the underlying ethical issues that appear to account for much of the divergence among OPOs' consent practices for cadaveric solid organ procurement.

A survey of use of a durable power of attorney to admit geropsychiatric patients.

Medical directors from 198 inpatient psychiatric facilities in 46 states completed a survey on the use of a durable power of attorney for health care to compel admission of unwilling patients with dementia. About half the facilities had a policy allowing use of a power of attorney for this purpose. Thirty-four percent believed that it was optional to use either a durable power of attorney or an involuntary commitment to force admission of demented patients, whereas 47 percent believed that such patients could be admitted against their will only through involuntary commitment.

End-of-life decision making in the intensive care unit.

Physicians are increasingly involved in how their critically ill patients die [72]. The more this happens, the more physicians will have to understand not only how their own backgrounds and biases influence their medical management, but also the cultural and religious backgrounds of the patient and surrogate [72, 73]. The medical profession must realise that, despite tremendous advances in medical knowledge and technology, not everyone can be saved all the time, even in the area of intensive care. Physicians must understand that "doing everything" that is best for the patient may not mean starting epinephrine or performing CPR, but rather may imply moving from a process of curing to caring with palliative care [10]. This process should be initiated by discussions with the patient or surrogate, and should include knowledge of the patients' wishes as demonstrated by advance directives and durable power of attorney. The patient's code status and the intention of forgoing life-sustaining treatment should be discussed with other members of staff together with the patient and/or family in a compassionate and humane manner. The wishes of the patient and family should be taken into consideration and the physician must try to make an impartial decision by doing what is medically and ethically correct and best for this specific patient. Hopefully, in this way, a more ethical and compassionate approach to end-of-life decisions in the ICU will be obtained.

The attitude of Canadian nurses towards advance directives.

This article seeks to shed light on the beliefs that influence nurses' intention of respecting or not respecting an advance directive document, namely a living will or a durable power of attorney. Nurses' beliefs were measured using a 44-statement questionnaire. The sample was made up of 306 nurses working either in a long-term care centre or in a hospital centre offering general and specialized care in the province of Québec. The results indicate that nurses have a strong intention of complying with advance directives written by patients. The analysis also shows that four variables determine the strength of this intention: respect for autonomy; the location of the workplace; justice; and the dimension of relationships and emotions. Although these documents favour the expression of patients' wishes, nurses should be aware that they do not systematically guarantee respect of a patient's autonomy, nor do they replace a relationship based on trust between patients and health care professionals.

At Law: The Best-Laid Plans

It is natural to suppose law is like the centurion and can do as it will: I say to this man, Go, and he goeth; and to another, Come, and he cometh; and to my servant, Do this, and he doeth it. But a thousand years ago, King Canute tried to disillusion his courtiers about his efficacy by commanding the waves to stop beating. And fifty years ago, Harry Truman predicted of Dwight Eisenhower, sit here, and he'll say, `Do this! Do that!' And nothing will happen. Poor Ike--it won't be a bit like the Army. He'll find it very frustrating. It is natural to suppose law can do as it will because law has imposing powers. It can spend. It can fine. It can imprison. It can kill. So armed, surely it can command obedience. Sometimes it can. But surprisingly often, laws disappoint. They rarely fail completely. But, with dismaying frequency, laws betray the expectations of their promulgators and their advocates. The law of bioethics is no exception. In recent decades, courts and legislatures put several central bioethical ideas into law. These reforms seemed surpassingly logical. Yet today many of them look puzzlingly ineffectual. A new study of informed consent typifies the results that dismay. Clarence Braddock and his colleagues taped 1,057 encounters between doctors and patients. Their report: Overall, the completeness of informed decision making low.... [F]ew decisions (9.0%) met criteria for completeness of informed decision making. The authors thought their findings suggest that the ethical model of informed decision making is not routinely applied in office and that the low level of informed decision making suggests that physicians' typical practice is out of step with ethical ideals.[1] The Braddock study is all too easily duplicated in other contexts. It examines what doctors tell patients. Other studies investigate the forms used to obtain consent and found them opaque. Yet other studies tested patients after they received information and find they trouble remembering and understanding what they are told. Still other studies are gloomy about efforts to warn prospective subjects of medical experiments that they are unlikely to benefit therapeutically from participating. As one summary puts it, studies have shown that patients remain inadequately informed, even when extraordinary efforts are made to provide complete information and to ensure their understanding.[2] Informed consent is perhaps the oldest of these attempts to put bioethical principles into law. It is also one of the best accepted; who today would appear in print to denounce giving patients the information they need to make decisions? If informed consent disappoints, what legal reform can hope to do better? But informed consent is not alone in disappointing. Advance directives quickly found legal favor when they were proposed, yet their promise remains unrealized. Most people do not an advance directive. Even people who particular reason to use them do so less frequently than commentators want: Although chronic dialysis patients support and favor advance directives in principle, only 28% to 38% of dialysis patients complete advance directives.[3] Even when advance directives are signed, they are not always available when needed. One inquiry discovered that only a quarter of the advance directives incompetent patients executed were documented somewhere, somehow in the patient's chart.[4] And even when advance directives are available, it is unclear how well they work. One study even found care was, perversely, less likely to be consistent with patients' previously expressed wishes when the advance directive available.[5] Thus one of the SUPPORT studies concluded that standard living wills do not effectively direct care decisions for seriously ill adults.[6] The Patient Self-Determination Act was enacted specifically because so few individuals complete advance directives and because `the living will, and its close relative, the durable power of attorney [were] counted as abject failures with respect to the protection of autonomy'. …

Predictors of driving cessation, independent living, and power of attorney decisions by dementia patients and caregivers

This study examines factors associated with decisions made by dementia patients and their caregivers regarding whether the patient should cease driving, live alone or with their spouse, and assign a Durable Power of Attorney. Using data collected by the Alzheimer's Disease Research Center (ADRC) in the Memory Disorders Clinic at the University of Kentucky Medical Center, we analyzed 827 first visits to predict patients’ and caregivers’ decisions. Caregiver relationship and patient gender and perceptions of patient abilities, as measured by Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) were more important than cognitive functioning, as measured by the MMSE, in predicting decisions made. These findings have theoretical implications for modeling the impact of the course of the disease and practical implications for interventions aimed at supporting the decision-making processes of patients and caregivers.

Cultivating Conscience: Learning to Make End-of-Life Decisions in the Emergency Department

Cultivating Conscience: Learning to Make End-of-Life Decisions in the Emergency Department