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Advanced Directives Essay Research Paper CONTENTSI INTRODUCTION

Advanced Directives Essay, Research Paper



II. Will Your Advance Directive be Honored? 4

III. What are Advanced Directives 5

IV. Advanced Directives Fall Short 5

V. Who Decides 7

VI. Why are Advanced Directives not Followed 8

VII Conclusion 9


Introduction 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.

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, advanced 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).

What are Advanced Directives

Advance directives, also known as living wills, and health care proxys 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 clients 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?

Advanced Directives Fall Short

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 clients who subsequently became incompetent.

The physicians interviewed indicated that they would only follow a client’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 client’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 clients were transferred from ambulatory to acute care settings, only 26 percent of the clients 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 clients. 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 clients control. How disheartening for a person to fear that the doctor cannot be trusted in a matter of such importance. It appears that many doctors have no respect for their clients’ wishes.

Who Decides

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

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 client autonomy. 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 clients’ choices, they may explain their reluctance as a disagreement about whose judgment is better – theirs or their client’s (King, p. 52). Also, physicians may give their own ethical principals priority when they conflict with clients 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 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 client in the given circumstances and unilaterally decide to withhold or withdraw treatment. (p. 93)

Why are Advanced Directives not Followed

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 person’s wallet for people to contact, finds a living will card. If heroic measures are applied in an emergency situation, placing the client on life-support systems, it is sometimes very difficult to remove them (King, p. 91).


This paper offers insight into many different reasons why the Advanced Directives are not always followed. It is sad but it is often true that the wishes, made known in advanced are still not followed at the time they are needed. There is much work still needing to be done to have advanced directives work the way they are intended.

I feel much of the responsibility lies with the clients themselves to educate their families as to their wishes when the time comes. The subject should also be discussed with the primary Physician. There should be copies on file with both the primary Physician, and the hospitals the client uses. I still have mixed emotions on the role of the family to overturn the line of the advanced directive. I do think the family, who presumably knew the client best should have the ability to say what the client most likely would have wanted in the case of an unexpected event not specifically stated in the advanced directive.

I do not feel that making more laws will help the situation unless you are willing to put people in jail for not following the “contract” of Advanced directives. No, more laws will not help except to perhaps make a universal format for advanced directives. That may help in the cases of “but, that was written in another state”. I feel the key to success is continued understanding and teamwork, in the medical field.

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.