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Institutional quandaries.

During a recent presentation I made about the Patient Self-Determination Act to the medical staff of a nearby community hospital the following questions were among those raised by attendees: * What information, exactly, should be made available to patients, and by whom? * Should families be present during conversation that ensues about the act, or should the competent patient have the prerogative of whether to share the information with family members? * When should the exchange regarding advance directives and a patient's rights to accept or refuse treatment take place? * Do nurses, therapists, and other members of the health care team have a role to play in implementing the act? * Am I protected from having to follow some aspect of the act's mandate, or the policies flowing from it, that would compromise my own moral convictions?

Institutional administrators, upon whose shoulders it has fallen to design and oversee staff education and institutional policy formation related to the act, will find the basic framework for their activities in the ethical concerns expressed through these clinicians' questions. At least three general areas are appropriate focuses for administrators' activities: the professional promise to maintain patient dignity and show respect for individual differences; the practical reality that high ethical standards require effective teamwork in patient care; and the societal promise that health professionals' own professional integrity will be recognized.

Maintaining patient dignity. Administrators will differ among themselves regarding the role they believe advance directives play in realizing the act's goal of allowing adult patients to maintain an active voice in their treatment. Whatever the administrator's position, it would be a mistake to focus staff education and policy on advance directives alone. Advance directives have arisen in response to the challenges life-threatening illness or incapacity pose to patients' dignity and autonomy. The act offers an opportunity for clinicians, administrators, and others to rethink the full scope of attributes and behaviors that foster a patient's self-respect in such extreme circumstances. Particularly relevant are concerns about communication in professional-patient and hospital-patient relationships: Alexander M. Capron creates a plausible nightmare scenario of advance directives being signed in the presence of admissions clerks only (HCR 20, no. 5 [1990]: 3536). To be avoided at all costs is bureaucratic satisfaction that patients are being efficiently "Danforthed"-while not given the full respect they deserve. The increasing awareness that patients' statements about end-of-life decisions must be further clarified to discern their real wishes should provide a helpful directive for staff education and policy initiatives. Furthermore, since good communication is but one means of fostering patient self-respect, the act should be a catalyst for all institutions to review basic policies related to direct patient care, such as issues of confidentiality and information sharing, the timing of various interventions, worries about a compromise of professional competence, and the difficulty of tailoring any regulation to individual patient needs.

Team issues. The mandate for staff education places administrators in an apt position to reiterate the necessity of effective teamwork among all involved in a patient's care. The fragmentation that sometimes plagues the process of obtaining informed consent for various procedures easily could be experienced in trying to implement the act as well. Prospective planning and education will enable the team to maintain their own effective and efficient functioning as well as provide the patient with a well-coordinated approach to the delicate issues the act addresses.

Personal integrity of professionals. Many institutions maintain policies aimed at protecting the professional employee from having to participate in procedures or other activities that compromise the person's religious beliefs and other deeply held values. In our pluralistic society the PSDA challenges administrators in that it is silent on what an institution should do about employees who believe that the act presents morally reprehensible options to patients. The wording assumes that patients simply will be given all the information. At the very least, staff education should include an opportunity for the rich diversity of belief and opinion among members to be aired and dealt with in an environment of support; such education can include an emphasis on employee-generated mechanisms to exempt direct involvement of individuals whose convictions preclude them from participating in the act's implementation in good conscience. The principle of respect for the professional as a person combined with a clear standard of what is required in the professional role the person voluntarily has assumed will be an apt guide for ascertaining the appropriate extent to which his or her convictions can be honored.

Equally important as a focus of education and policy is to spell out safeguards regarding personal religious beliefs of professionals. This, too, is an opportunity to review existing or needed institutional approaches that show respect for the professional as a person.

In summary, the act is best viewed from a staff education and policy point of view as being within the broader context of good patient care that requires competent, individualized, and thoughtful approaches to patient problems. Rather than to treat the act administratively as a unique regulation, the focus should be on policies and practices designed to maintain patients' dignity, foster effective communication and documentation, stimulate effective teamwork, and honor health professionals' moral beliefs. Ruth B. Purtilo is Professor of clinical ethics, Center for Health Policy and ethics, Creighton University, Omaha, Neb.

. .provide that the State, acting through a State agency, association or other private nonprofit entity, develop a written description of the law of the State . . . concerning advance directives that would be distributed by providers or organizations

The Secretary shall assist appropriate State agencies . . . in developing the Statespecific documents that would be distributed providers under the requirements . . . -PSDA
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Title Annotation:Practicing the PSDA; Patient Self-Determination Act
Author:Purtilo, Ruth B.
Publication:The Hastings Center Report
Date:Sep 1, 1991
Previous Article:Community education.
Next Article:The spirit of the PSDA.

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