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PSDA in the clinic.

A great majority of patients in the ambulatory setting welcome the opportunity to discuss advance planning for health care in case of mental incompetence. While it is commonly assumed that advance planning is relevant for the old or sick alone, planning with young and healthy patients may be considered analogous to screening for illness: the chance of illness is low, but the effort may be worth it.

The initiative for advance planning should come from the physician and should be understood to be part of standard care. If a patient has a document already, die physician should review and discuss it, and should recommend a clearer or more specific document if need be. Physicians should see their function as educational, guiding patients to pertinent information (bearin in mind their health status) and asking appropriate questions regarding issues raised in circumstances of life-threatening illness and mental incompetence. Specific preferences should be explored, especially where they are apparently not sensible, to correct misunderstandings or understand atypical values. Irresolvable differences in values between patient and physician that may potentially compromise the physician are indications for asking the patient to agree to transfer of care should the circumstances in question arise.

Admission. To the extent that the Patient SelfDetermination Act aims to bring patients' advance directives to the attention of the medical caretakers, admission to a health facility is a practical point at which to do so for a great majority of patients. But whether it is enrolling in a health maintenance organization or arriving in a hospital emergency ward, this time is not likely to be opportune for any substantive discussion of patients' values and treatment preferences. Activities should be restricted to providing informational brochures and identifying resources and to documenting whether the patient has preexisting directives.

Role of a health care planning nurse. Ultimately, advance planning should occur in the context of a physician-patient dialogue. However, much of the necessary information and guidance can be provided by a nurse specializing in health care planning, especially if the nurse is provided with a health profile of the patient. Health care planning nurses should be able to inform patients and their families or designated proxies about concepts of advance planning, documents available, basic legal requirements, and so forth; they should be able to guide the patient through tentative completion of a document. They should, however, always seek to involve the physician for the actual completion of the document.

Completing die directive. Completing directives in the context of a physician-patient discussion is important for several reasons. Patients can be educated about what decisions are pertinent; they can be provided with illness scenarios and further information; any misconceptions they may hold can be corrected. In helping patients to refine their directives physicians are provided with a unique opportunity to gain insight into the patient's health care goals and values. For a similar understanding, the next of kin or proxy designate should be encouraged to participate in the process of advance planning.

What document? Written statements are unlikely to provide for all possible circumstances, and proxy decisions are known to reflect the preferences of the patient poorly. The burden of being a proxy is also often underestimated. It is therefore necessary to combine written directives with surrogate decisionmaking.

The written statement can be guided by the use of illness scenarios allowing a patient to state his or her preferences regarding specific life-sustaining interventions. Statements about their goals for medical care in each scenario can be solicited (for example: comfort care, or dignity over longevity, or prolonging life despite suffering, etc.). More general statements about values can also be sought.*

Written directives for medical care should be considered more as interpretive guides for the physician and proxy, that is, as evidence of the patient's wishes, than as water-tight legal imperatives. This should be made explicit in the document. Medical treatment preference statements can be appended to more formal legal documents, such as state statutory documents.

Documenting directives. Directives should be made a part of the patient's active medical records and their existence flagged in some fashion. They may remain sealed until the patient is found to be incompetent to make treatment decisions. Wallet cards or bracelets noting the location of the directive should be made an option. Registries of living wills should be made available. Copies of the directive should be given to the physician if there are separate office records, to the family and proxy designate, and to any other involved party.

Follow-up and revision. Patients' advance preferences have been found to be quite durable. Nevertheless, revision of preferences should be anticipated and allowed for. It is prudent to review documents routinely-at times of major life events such as marriage, new parenthood, and bereavement; at times of major changes in health status; and, whenever possible, on admission to the hospital or other health care facility.

Implementing directives. The next of kin or proxy designate should be given a strong role in discussing patient care decisions with the physician. The proxy's intent should be to attempt substituted judgment for the patient. Although best-interests standards are also used by some proxies, identifying the patient's best interests should often be left to the physician. A balanced discussion should include the patient's statements of preference, the proxy's interpretation of patient preferences, and considerations raised by the physician and other involved parties. Ultimately, guided by the physician and other caregivers, the proxy must try to make decisions as the patient would have done for him or herself * A document combining these features is available from Harvard Medical School Health Publications, P.O. Box 380, Boston, MA 02117. Linda Emanuel is assistant director, Division of Medical Ethics, Harvard Medical SchooL

...shall not be construed as requiring the provision of care that conflicts with an advance directive.

The written information ..shall be provided to an adult individual* in the case of a hospital, at the time of the

individual's admission as an inpatient, * in the case of a skilled nursing facility, at

the time of the individual's admission as a

resident ...
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Title Annotation:Practicing the PSDA; Patient Self-Determination Act
Author:Emanuel, Linda
Publication:The Hastings Center Report
Date:Sep 1, 1991
Previous Article:Trumping advance directives.
Next Article:Honoring broader directives.

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