Morality Of Advanced Directives Essay, Research Paper

Abstract

This paper presents an in-depth discussion about the issues

involved in honoring a patient?s advance directive. Ethical

considerations surrounding the issue as they relate to the nursing

profession are addressed. The purpose of the paper is to express

an informed position on the issue of honoring a patient?s advance

directive and explore reasons why one may not be honored. The topic

was chosen on account of personal observation and awareness in an

acute care setting. The sources used to develop this paper are

published nursing journals, current books related to this issue, and

the Internet. The paper concludes with recommendations to assist the

professional nurse in dealing with issues related to honoring a

patient?s advance directive.

Will Your Advance Directive be Honored?

Advances in medical technology have done a great deal to

produce miraculous cures and recoveries. In some circumstances

however, these advances have created problems for the elderly. More

aggressive technology approaches are used to extend the life of the

elderly. On the whole the elderly, as well as others, welcome that

development — even if they fear some of its consequences. With these

advances it has become possible to keep people in a vegetative state

for almost unlimited periods of time. Moreover, there are situations

in which neither the patient nor the family has the ability to bring

such unhappy circumstances to an end. For this reason, advance

directives are becoming increasingly prevalent. In a recent study,

King (1996) reported that approximately 90% of the American public

want advance directives. Both the young and the healthy express at

least as much interest in planning as those older than 65 and those in

fair to poor health (p. 77). According to Lynne (1986) nurses play a

significant role because they attend to the patient continuously and

have an especially strong claim to be allowed the opportunity to be

comfortable with the care plan (p. 216).

Advance directives, also known as living wills, are documents

that a person can complete to ensure that health care choices are

respected. An advance directive only comes into play if a person

cannot communicate wishes because the person is permanently

unconscious or mentally incapacitated. A 1991 law called The Patient

Self Determination Act (PSDA) requires hospitals and nursing homes to

tell patients about their right to refuse medical treatment. People

can put anything in their advance directives. Some people list every

medical intervention they do not want, while others want to make clear

their request for heroic measures at any cost. It is a way to spell

out personal wishes. It is crucial that the issue of advance

directives and the issue of euthanasia not be confused. These issues

couldn?t be more dissimilar. Euthanasia is largely illegal. Advance

directives are seen as a way to protect one?s legal rights for

refusal of treatment. But are advance directives effective in

achieving the aim intended?

There is evidence to indicate that advance directives alone

fall far short of their objective. In a recent study conducted at

Harvard Medical School, Fishback (1996) reported 66% of all physicians

interviewed felt there was nothing wrong with overriding a patient?s

advance directive, even if the directive unambiguously stated the

conditions for the withdraw and withholding of medical treatment.

Fishback also reported 40% of the physicians questioned chose a level

of care different from that requested in advance by patients who

subsequently became incompetent. The physicians interviewed indicated

that they would only follow a patient?s advance directive if it was

consistent with their own clinical judgment. The physicians indicated

that they wanted to reserve the right to make clinical judgments about

treatment regardless of a patient?s request. In another study, Docker

(1995) reported on a study where 900 patients were studied over a

period of ten years. In very few cases did advance directives have

any influence over decisions to withdraw or withhold life prolonging

treatment. The passage of the PSDA half way through the study changed

their effectiveness by barely one percent. A study conducted in the

state of Utah, among 1398 participants, found little evidence that

advance directives affect life sustaining treatments (Jacobson,

Kasworm, Baltin, Francis, Green, 1996). Jaffe and Ehrlich (1997)

report ?unfortunately, the advance directive movement has not had

great success . . . breakdowns occur with alarming frequency in the

chain of responsibility to observe them? (p. 145). When patients were

transferred from ambulatory to acute care settings, only 26 percent of

the patients who had advance directives had them recognized by the

admitting hospital (Jaffe & Ehrlich, p. 143).

These statistics command our attention. They also make us

focus on the tension and disagreement that exists between physicians

and their patients. The population clearly seeks more control over

both their future medical care and also the method, timing, and place

of their death. Patients want ?. . assurance that there will be no

unreasonable efforts, an affirmation that the dignity to be sought in

death is the appreciation by others of what one has been in life. . .

the acceptance of one?s own death is a necessary process of nature . .

.?(Nuland, 1993, p. 255). Yet these statistics show that physicians

often do not allow patient control. How disheartening for a patient

to fear that the doctor cannot be trusted in a matter of such

importance. It appears that many doctors have no respect for their

patients? wishes. According to Edwards (1994), nurses as patient

advocates have a responsibility to make sure patients? wishes are

respected; it is nursing?s role to raise informed questions and even

objections if a patient?s treatment violates the patient?s wishes.

Without strenuous interventions to improve the situation, we will have

expended a vast effort to establish something that basically doesn?t

work. Let?s evaluate the reasons for the failure to implement a

patient?s advance directive.

In one study, nurses indicated that family opposition to the

terms of the advance directive was the primary factor that inhibited

health care providers from following the patient?s living will

(Weiler, Eland, Buckwater, 1996). When families contradict the

patients wishes, physicians take their views under consideration

giving them immense weight. After all, who does the physician have to

answer to? The living, of course. This is why when the family

disagrees with the advance directive, the family?s decisions usually

win out. Dealing with death and suffering on a daily basis does not

make it easy for medical professionals to make decisions about

removing life support. Most make an effort to be as dispassionate as

possible about such situations so that families can make informed

decisions. The result is that the profession tends to err on the

conservative side (Edwards).

Another factor for the failure to follow an advance directive

was the treating physician?s refusal (Weiler et al). One reason for

the physician?s refusal may be reluctance to acknowledge increasing

patient autonomy. After all, the medical decision horizon looks

substantially different today than it did just a few years ago. Before

the 1960?s physicians enjoyed a substantial degree of autonomy in

making treatment decisions for, rather than in conjunction with their

patients. Unlike in the 1980?s and 1990?s, where medical decision

making has become radically transformed from what once was a matter of

professional concern into what has become a matter of individual

choice. Change is in the air, brought on by forces that have put

pressure on members of the medical profession to ease their control on

patient care and treatment decision making. ?The days of autonomous

physician ruling by fiat without much consideration of patients wishes

are slowly drawing to a close? (Hoefler, 1994, p. 191). According to

Hoefler, ?dramatic changes in the medical profession itself have led

to a breakdown in patient trust?. Another reason for their refusal

may be that it is unmistakably apparent that medical paternalism still

exists. ?A lingering paternalistic attitude on the part of many

physicians is fostering distrust. If the treatment preferences of

patients are to be honored, doctors may face the difficult prospect of

relinquishing, at least in part, this central element of their

professional role? (King, 1996, p. 51-52). Still another reason

physicians may refuse is a for-your-own-good reasoning. If physicians

are reluctant to honor patients? choices, they may explain their

reluctance as a disagreement about whose judgment is better – theirs

or their patient?s (King, p. 52). Also, physicians may give their

own ethical principals priority when they conflict with patients

wishes. This is reflected in the following statement by J.M. Hoefler:

When a patient?s advance directive was too restrictive to

allow a simple or basic procedure that would yield the patient

substantial benefits from the physician?s perspective, the

physician gave their own ethical principals priority. The

reverse may also be true: Despite an advance directive

requesting that treatment be provided, physicians may judge

that treatment would be of little benefit to the patient in

the given circumstances and unilaterally decide to withhold or

withdraw treatment. (p. 93)

Fear of litigation is another factor. Added to the moral, ethical and

humane considerations, physicians also must keep the legal risks in

mind. No group is more subject to the risks of litigation than the

medical profession. The medical professional does not want to be

accused of pressuring the family for removal of life support, or to

be second guessed by other medical personnel in a court of law. Even

when advance directives that would seem to protect the physician are

executed, relieving the physician of some liability, physicians may

not comply with their patient?s wishes (Hoefler, p. 93).

Uncertainty about the meaning and application of a directive

is another reason for not implementing an advance directive once it

has been found and examined. The law on honoring advance directives

from one state to another is unclear. ?Actually the forms are not

significant legal documents in and of themselves? (Purtilo, 1995,

p. 132-133). ?Even a signed living will could be disqualified if it

failed the court?s measure for being not recent enough, not logically

consistent, or not specific enough? (Lynn). Interpreting advance

directives can be problematic at times, as when information is

lacking, or when a strict reading of the document does not seem to

make sense. For example, the advance directive may suggest one course

of care, while the physician and/or family believe the patient would

in fact have wanted something else. No advance directive can

anticipate every situation that could possibly arise.

Emergency circumstances can be another barrier to the

implementation of advance directives. The emergency room physician

treating an accident victim is not really in a position to halt things

immediately when a nurse, looking through the patient?s wallet for

people to contact, finds a living will card. If heroic measures are

applied in an emergency situation, placing the patient on life-support

systems, it is sometimes very difficult to remove them (King, p. 91).

Some believe that discussing advance directives upon admission

to a health care facility is yet another factor. Some would argue that

this is the wrong place and the wrong time. The PSDA made it necessary

for every patient to be asked, upon admission to a health care

institution if they have an advance directive or want to prepare one

and to supply them with the forms. Many institutions are largely

paying ?lip service? to this matter. ?Many institutions, reluctant to

give the appearance of proselytizing about advance directives, do

little to initiate discussions with new patients who do not have them?

(King, p. 110). Many hospital personnel whose job it is to answer

questions and help patients execute advance directives have

insufficient training. Perhaps the PSDA needs to be modified. The

PSDA has, however, increased the public?s knowledge. More still needs

to be done. Why, then, should an information giving requirement

concerning advance directives be applied not to physicians but to

health care institutions? Most would agree that the outpatient setting

is the best place and time for such discussion. The physician and

patient could discuss this issue one to one before an admission to a

hospital or long term care facility. If advance directives are to

become an integral part of health care it is essential to implement

interventions that would make a difference. What can nurses do if they

believe a patient is being treated contrary to the spirit or letter of

an advance directive?

According to the American Nurses Association Code of Ethics (ANA,

1985):

Clients should be as fully involved as possible in the

planning and implementation of their own health care. Clients

have the moral right to determine what will be done with their

own person; to be given accurate information, and all the

information necessary for making informed judgments; to be

assisted with weighing the benefits and burdens of options in

their treatment; to accept, refuse, or terminate treatment

without coercion; and to be given necessary emotional support.

Each nurse has an obligation to be knowledgeable about the

moral and legal rights of all clients and to protect and

support those rights.

Nurses can make sure everyone on the health care team knows

the document exists, beginning with the physician. Place it in a

conspicuous position on the patient?s chart and label the chart, if

necessary.

State laws may place some restrictions on advance directives

or a patient may have one from another state. If, after reading an

advance directive, a nurse is unsure whether it meets the state?s

requirement, the hospital?s risk manager, nursing administrator or

ethics committee should be asked to review the document with the

nurse (Edwards).

Nurses in the outpatient setting can educate patients to ask

their physicians to make their advance directive part of their medical

record, they should keep a copy where it can be found easily and to

communicate their wishes clearly to their family and physician and be

sure they are understood.

Providing psychosocial support for patient and family has

always been an essential part of nursing. Nurses may well be trusted

in large part because they are presumed to act in defense of their

patients lives. Nurses give great importance to the psychosocial

health of their patients. According to Smith, most professional

literature related to the psychosocial care of the dying is written by

nurses. ?The dichotomy between nursing and medicine is striking in

this regard? (Smith, 1985, pg. 284).

Nurses will undoubtedly, sometime during their career, be

faced with similar challenges. However, being focused on the nurse?s

most significant role as a patient advocate, will assist the nurse

when making incisive decisions.

—

References

American Nurses Association. (1985). American Nurses

Association Code for Nurses with Interpretive Statements, Section 1.1.

Washington, DC:ANA.

Docker, C. (1995). Deciding How We Die. The use Limits of

Advance Directives. [On-line]. Available:

http://www.finalexit.org/wfn27.3.html.

Edwards, Barbara S. (1994). When a living will is ignored.

American Journal of Nursing, 94(7), 64-5.

Fishback, R. (1996). Harvard Medical School Division of

Medical Ethics. Care Near the End of Life. [On-line]. Available:

www.logicnet.com/archives/file2001.php.

Hoefler, J.M. (1994). Deathright: Culture, Medicine, Politics

and the Right to Die. Boulder, CO:Westview Press.

Jacobson, J.A., Kasworm, E., Baltin, M.P., Francis, L.P., &

Green, D. (1996). Advance directives in Utah. Journal of American

Medical Association, 156, 1862-1868.

Jaffe, C., & Ehrlich, C.H. (1997). All Kinds of Love:

Experiencing Hospice. Amityville, NY:Baywood Publishing.

King, N. (1996). Making Sense of Advance Directives.

Washington, DC:Georgetown University Press.

Lynne, Joanne. (1986). By No Extraordinary Means. Bloomington,

IN:Indiana University Press.

Nuland, S.B. (1993). How We Die. New York:Vintage Books.

Purtilo, R. (1995). Ethical Dimensions in the Health

Profession. Philadelphia:W.B.Saunders.

Smith, Walter, J. (1985). Dying in the Human Life Cycle. New

York:Holt, Rinehart, & Winston.

Weiler, K., Eland, J., & Buckwater, K.C. (1996). Iowa nurses?

knowledge of living wills and perceptions of patient autonomy. Journal

of Professional Nursing, 12(4), 245-252.