PubMed Health⌕ Search

Biomedical subjects

L L Emanuel

Publications and source records attributed to L L Emanuel.

50 records · Page 3Linked to original sources
PubMed1991

Advance directives for medical care--a case for greater use.

UNLABELLED: BACKGROUND. Advance directives for medical care and the designation of proxy decision makers to guide medical care after a patient has become incompetent have been widely advocated but little studied. We investigated the attitudes of patients toward planning, perceived barriers to such planning, treatment preferences in four hypothetical scenarios, and the feasibility of using a particular document (the Medical Directive) in the outpatient setting to specify advance directives. METHODS: We surveyed 405 outpatients of 30 primary care physicians at Massachusetts General Hospital and 102 members of the general public in Boston and asked them as part of the survey to complete the Medical Directive. RESULTS: Advance directives were desired by 93 percent of the outpatients and 89 percent of the members of the general public (P greater than 0.2). Both the young and the healthy subgroups expressed at least as much interest in planning as those older than 65 and those in fair-to-poor health. Of the perceived barriers to issuing advance directives, the lack of physician initiative was among the most frequently mentioned, and the disturbing nature of the topic was among the least. The outpatients refused life-sustaining treatments in 71 percent of their responses to options in the four scenarios (coma with chance of recovery, 57 percent; persistent vegetative state, 85 percent; dementia, 79 percent; and dementia with a terminal illness, 87 percent), with small differences between widely differing types of treatments. Specific treatment preferences could not be usefully predicted according to age, self-rated state of health, or other demographic features. Completing the Medical Directive took a median of 14 minutes. CONCLUSIONS: When people are asked to imagine themselves incompetent with a poor prognosis, they decide against life-sustaining treatments about 70 percent of the time. Health, age, or other demographic features cannot be used, however, to predict specific preferences. Advance directives as part of a comprehensive approach such as that provided by the Medical Directive are desired by most people, require physician initiative, and can be achieved during a regular office visit.

Advance Directives↗
PubMed1989

The Medical Directive. A new comprehensive advance care document.

Living wills have been strongly endorsed in principle. Unfortunately, existing living wills are rarely used in clinical practice because they are vague and difficult to apply. To remedy this, we propose a new advance care document: the Medical Directive. The Medical Directive delineates four paradigmatic scenarios, defined by prognosis and disability of incompetent patients. In each scenario, patients are to indicate their preferences regarding specific life-sustaining interventions. The Medical Directive also provides for the designation of a proxy to make decisions in circumstances where the patient's preferences are uncertain. Finally, there is a section for a statement of wishes regarding organ donation. The Medical Directive provides an opportunity for significant improvement in the documentation of patients' preferences regarding life-sustaining care in states of incompetence. As an expression of a patient's wishes, the Medical Directive should be honored by courts and should facilitate physician-patient discussions of critical and terminal care options.

Brain Diseases↗
PubMedDate not supplied

Gaps in end-of-life care.

Every year, more than 1 million Americans die of different causes. Some die easily and comfortably. Others die with a great deal of suffering and distress. This article contrasts key aspects of the way Americans die with the way they say they would like to die. It will also highlight some of the barriers to providing high-quality end-of-life care. Arch Fam Med. 2000;9:1176-1180

Attitude to Death↗
PubMedDate not supplied

Advance care planning.

Advance care planning is the process of planning for future medical care, particularly for the event when the patient is unable to make his or her own decisions. It should be a routine part of standard medical care and, when possible, conducted with the proxy decision maker present. It is helpful to think of the process as a stepwise approach. The steps include the appropriate introduction of the topic, structured discussions covering potential scenarios, documentation of preferences, periodic review and update of the directives, and application of the wishes when needed. The steps can be integrated flexibly into routine clinical encounters by the physician and other members of the health care team. The process fosters personal resolution for the patient, preparedness for the proxy, and effective teamwork for the professionals. The process also has pitfalls of which to be aware. Arch Fam Med. 2000;9:1181-1187

Advance Directives↗
PubMedDate not supplied

Reexamining death. The asymptotic model and a bounded zone definition.

The traditional Western understanding of life and death as a strict dichotomy is challenged by a more descriptively accurate model of life's progressive cessation. Dying can be defined by a bounded zone of residual states of life that fits better with moral intuition and more sensitively guides action toward the dying.

Aged↗
PubMedDate not supplied

Decisions at the end of life. Guided by communities of patients.

To guide treatment decisions for incompetent patients who have no advance directives, health care institutions should look to the preferences of their own communities of patients. That is the best way to ensure that incompetent patients' wishes will be followed.

Advance Directives↗