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Results for “Advance Directive Adherence”

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PubMed1998

Patient values: the guide to medical decision making.

Physicians are increasingly challenged by issues surrounding medical decision-making for hospitalized patients. Advance directives express a patient's preferences regarding end-of-life care; when available, they should be used to guide medical treatment. Patients who lack decision-making capacity require special consideration to ensure maximal patient participation with appropriate surrogate involvement. An ethics committee consultation may be especially helpful to resolve conflicts that may arise regarding medical treatments. Physicians play a vital role in promoting earlier patient-physician discussions about end-of-life care preferences, increased completion of advance directives, and ongoing education for physicians to improve communication skills.

Advance Care Planning↗
PubMed1995

The Patient Self-Determination Act. A matter of life and death.

The Patient Self-Determination Act (PSDA) is a federal law, and compliance is mandatory. It is the purpose of this act to ensure that a patient's right to self-determination in health care decisions be communicated and protected. Through advance directives--the living will and the durable power of attorney--the right to accept or reject medical or surgical treatment is available to adults while competent, so that in the event that such adults become incompetent to make decisions, they would more easily continue to control decisions affecting their health care. Without advance directives and the proper adherence to such directives, former President Richard Nixon and former First Lady Jacqueline Kennedy Onassis might still be alive today, in persistent vegetative states. This article examines the history of the act, its importance to each individual, the clinical, ethical and legal issues, and the role of health care professionals in effectively implementing and ensuring compliance of the PSDA.

Advance Directives↗
PubMed2006

Commentary: psychiatric advance directives at a crossroads--when can PADs be overridden?

Current statutes enabling psychiatric advance directives (PADs) typically include provisions allowing override of patients' choices by treatment staff. Lest the purpose of the PAD be vitiated by too broad an application of the override mechanism, its use should be carefully limited. In inpatient settings, voluntary patients should have the right to decline treatments in advance, although not an absolute right to demand treatments of their choosing. The situation of involuntary patients is more complex. Permitting PADs to trump commitment statutes would undercut the combined parens patriae/police power rationale for commitment, a path taken currently by no U.S. jurisdiction. Moreover, PADs should not be permitted to negate the usual mechanisms for involuntary treatment of committed patients; to do otherwise risks forcing facilities to confine indefinitely persons they cannot treat. Even in those circumstances, however, where PADs provide evidence of reasonable patient preferences (e.g., for one medication over another), the choices they embody should be respected.

Advance Directives↗
PubMed1993

Ethics consultants' recommendations for life-prolonging treatment of patients in a persistent vegetative state.

OBJECTIVE--Surprisingly little is known about the content of ethics consultants' recommendations. We chose to study this issue using hypothetical persistent vegetative state (PVS) cases. We addressed four questions: What recommendations do ethics consultants give regarding life-prolonging treatment (LPT) in PVS cases? To what degree is there consensus? What factors influence recommendations? Do recommendations conform to established guidelines? DESIGN--Questionnaire survey. Our questionnaire asked subjects what they would recommend for seven hypothetical vignettes involving a PVS patient that varied with respect to advance directives and family wishes. We also questioned subjects about demographic characteristics, ethics consultation experience, and personal preference for LPT in PVS. SUBJECTS--Attendees at an annual meeting of the Society for Bioethics Consultation (n = 154). RESULTS--The response rate was 77%. Eighty-one percent of respondents were ethics committee members and 62% were ethics consultants. There was general agreement among respondents for only one of seven vignettes: in the case of a PVS patient whose advance directive and family agree that LPT be stopped, 93% recommended stopping all LPT. Responses to other vignettes varied considerably. Although patient wishes were an important factor influencing recommendations, none of the respondents adhered invariably to the patient's advance directive. Recommendations were also influenced by family wishes, resource allocation considerations, legal constraints, and personal preference for LPT in PVS. Guidelines we examined were generally too equivocal to be useful for evaluating ethics consultants' recommendations. CONCLUSIONS--The finding of wide variability in ethics consultants' recommendations suggests a need to clarify standards for ethics consultation.

Coma↗
PubMed2005

The Palliative Care in Assisted Living (PCAL) pilot study: successes, shortfalls, and methodological implications.

Troubling deficits exist in palliative care (PC) of older adults under the prevailing "terminal care"-oriented model. We previously described a PC model--TLC--that provides a blueprint for remedying these shortfalls. In this model, PC is envisioned as Timely and Team-oriented, Longitudinal, and Collaborative and Comprehensive. We present results of the Palliative Care in Assisted Living pilot, comparing two TLC model-based, facility delivered interventions for improving the PC of elderly assisted living residents in Sacramento, California, a growing and under-researched population. The less intensive intervention involved one assessment followed by a PC improvement recommendation letter to the resident, family member, primary provider, and facility staff, while the more intensive intervention involved assessments and letters every three months. Primary outcomes were SF-36 Physical (PCS) and Mental (MCS) Component scores and recommendation adherence. Eighty-one subjects enrolled (mean age 85), 58 in the more and 23 in the less intensive group. A loved one attended 56% of baseline assessments. Most subjects expressed a preference for maintaining current quality of life over prolonging life at reduced quality. None were eligible for hospice care. A total of 418 recommendations (mean 5.1 per subject) were generated concerning symptoms, mood, functional impairments, and advance directives. We found no significant differences in recommendation adherence between more (42%) and less (44%) intensive groups, and no significant changes in PCS and MCS scores within or between groups. However, a loved one's attendance of the baseline assessment was associated with improved PCS scores (p=0.04). Our pilot study had methodological limitations that could account for the lack of significant outcome effects. In this context, and given the myriad unmet PC needs we detected, interventions based on the TLC model might allow delivery of timely PC to assisted living residents not eligible for hospice care. Further studies exploring the TLC model appear warranted.

Advance Care Planning↗
PubMed2005

Clinical and legal characteristics of inmates with bipolar disorder.

Individuals with bipolar disorder are at an increased risk of criminal arrest compared with those in the population at large. The combination of manic symptoms and substance abuse seem to be the primary illness factors for this increased risk, and the public mental health system has faced challenges in treating these patients successfully in community settings. To decrease the risk for arrest in bipolar patients, clinicians can screen and refer patients for substance use disorders, stabilize mania in hospital settings, and take measures to improve outpatient adherence in the postmanic hospitalization period. Psychiatric advance directives, new developments in civil commitment law, and mental health courts are legal mechanisms that may be critical in preventing the criminalization of those with bipolar disorder.

Bipolar Disorder↗
PubMed2003

Projecting the cost-effectiveness of adherence interventions in persons with human immunodeficiency virus infection.

PURPOSE: To explore the cost-effectiveness of interventions to improve adherence to combination antiretroviral therapy in patients with human immunodeficiency virus (HIV) infection. METHODS: A simulation model of HIV infection, incorporating CD4 cell count and HIV ribonucleic acid levels as predictors of disease progression, was used to estimate the lifetime costs and quality-adjusted life expectancy associated with clinical interventions to improve adherence to antiretroviral therapy (e.g., directly observed therapy, automatic medication dispensers, beepers, portable alarms) in a clinical trial cohort with early disease (mean CD4 count, 350 cells/microL), a clinical trial cohort with advanced disease (mean CD4 count, 87 cells/microL), and an urban cohort (mean CD4 count, 217 cells/microL). Data were from clinical trials, national databases, and published literature. RESULTS: For relatively healthy patients with early disease, interventions that reduced virologic failure rates by 10% increased quality-adjusted life expectancy by 3.2 months, whereas those that reduced failure by 80% increased quality-adjusted life expectancy by 34.8 months, as compared with standard care. The cost-effectiveness ratio was below 50000 US dollars per quality-adjusted life-year (QALY) for interventions costing 100 US dollars per month provided that failure rates were reduced by at least 10%, and for those costing 500 US dollars per month provided that failure rates were reduced by more than 50%. For both patients with advanced disease and those from an urban cohort, adherence interventions costing about 500 US dollars per month (e.g., directly observed therapy) had to reduce failure by about 25% to have cost-effectiveness ratios below 50000 US dollars per QALY. CONCLUSION: In patients with lower baseline levels of adherence or advanced disease, even very expensive, moderately effective adherence interventions are likely to confer cost-effectiveness benefits that compare favorably with other interventions.

Antiretroviral Therapy, Highly Active↗
PubMedDate not supplied

Patients' attitudes toward advance directives and end-of-life treatment decisions.

Much of the patient education about advance directives described in the literature involves explaining the purpose of advance directives to patients and guiding them through the process of issuing a directive. However, well over half of the subjects in this study claimed to know enough about the directives to issue one, and almost all subjects expressed a preference for issuing directives when healthy. Although health care agencies that wish to adhere to the PSDA must continue to ask all patients if they have issued an advance directive, aggressive patient education programs that press hospitalized patients to consider issuing an advance directive may be perceived by patients as coercive and uncaring. Patient education may be more likely to achieve the goals of the PSDA if it is provided before hospitalization and if patients are encouraged to discuss their care preferences with family members who would be in a position to speak for them at the end of life. Further study of the few patients who choose to issue an advance directive would be informative. When and why they chose to issue the directive should be explored. Patients who report issuing an advance directive but do not provide their physician or hospital with a copy of the directive upon admission should also be studied to determine if this represents a desire not to activate the directive during the current admission or simply confusion about the disposition of this document. Finally, most studies of advance directives have been cross-sectional. Longitudinal study of patients who issue advance directives are needed to determine the effectiveness of these documents in influencing the end-of-life treatment that patients receive.

Adult↗
PubMed2002

Advance directives and life-sustaining treatment: a legal primer.

Advanced directives are a natural extension of a patient's right to self-determination of what actions will be taken upon his or her body. As such, instructional advanced directives such as living wills and DNR orders represent important patient preferences that must be adhered to in the health care context. In addition, health care proxies provide the patient with an authority for decision making in the event of incapacity. Overall, advanced directives provide health care providers, patients, and patient families with control over the kinds of care they do and do not desire at the end of life. Understanding the legal status of these instruments will provide the physician with another tool to advocate effectively for the patient.

Advance Directives↗
PubMedDate not supplied

Advance directives: a program design for home healthcare.

Home care agencies receiving Medicare and Medicaid reimbursement are now required to adhere to the regulations of the Patient Self-Determination Act of 1990. These regulations require all agencies to inform clients older than 18 years of their right to plan for their care in advance, and to provide clients with the agency's written policy respecting this right. It also requires that agencies educate their staff about the new provisions. This report presents a program designed to orient all new and continuing home care staff members with the requirements to ensure compliance with this important directive.

Advance Directives↗
PubMedDate not supplied

Advanced directives and midwifery care.

The Patient Self-Determination Act was passed by the U.S. federal government in 1990 and became effective in December 1991. This federal law requires institutions that accept Medicaid funding to provide written information about rights to make decisions about medical care to all persons admitted for care. To meet federal guidelines, many health care institutions provide this information in the admission packet. Studies have shown that compliance with addressing this subject has been uneven at best and that providers may be uncomfortable discussing this issue with clients. Midwife-attended births accounted for 7.3% of all births in 2000. The majority of these births occur in the hospital setting; therefore, laboring women are subject to the Patient Self-Determination Act. This article addresses the responsibilities of the certified nurse midwife/certified midwives in counseling women and their families regarding advanced directives.

Adult↗