Who Decides?

2020 ◽  
pp. 41-48
Author(s):  
Kenneth V. Iserson
Keyword(s):  
Health Care ◽  
Decision Making ◽  
Living Will ◽  
Care Physician ◽  
Power Of Attorney ◽  
Health Care Decisions ◽  
Decision Making Capacity ◽  
State Statutes ◽  
Hospital Policies ◽  
Life Sustaining Treatment

To make a health care decision, individuals (whether it be the patient or an adult surrogate) must have decision-making capacity. Based on the principle of patient autonomy (respect for persons), such adults can make their own health care decisions, even if they contradict what their health care provider recommends. However, if a patient lacks decision-making capacity, his or her previously completed health care directive(s) take effect. These can be a living will, durable power of attorney for health care, Physician Orders for Life-Sustaining Treatment (POLST) form, or a similar document. In a similar manner, if an adult patient wishes to orally designate another adult to make his or her health care decisions (as in the case in this chapter), they may do that. These surrogates’ decisions carry the same weight as and replace any previously named surrogate. When no surrogate has been named, most hospital policies and many state statutes list the general hierarchy of people to be the patient’s surrogates.

Advance Directives, Do Not Resuscitate Orders, and Power of Attorney for Health Care

2018 ◽  
Author(s):  
Laura Stafman ◽  
Sushanth Reddy
Keyword(s):  
Health Care ◽  
Decision Making ◽  
Advance Directives ◽  
Advance Directive ◽  
Persistent Vegetative State ◽  
Living Will ◽  
Do Not Resuscitate ◽  
Power Of Attorney ◽  
Decision Making Capacity ◽  
Do Not Resuscitate Orders

In 2005, Terri Schiavo collapsed at home and was found by her husband without respirations or a pulse. She was resuscitated, but suffered severe anoxic brain injury and after 21/2 months was diagnosed as being in a persistent vegetative state. A court appointed her husband as her legal guardian as she did not have a written advance directive and had not specified a power of attorney for health care (POAHC), but heated court battles raged between her husband and her parents regarding who should be making decisions and what the appropriate decisions were. This case highlights the importance of writing down instructions for end-of-life care or designating someone to make decisions in their best interest in the event they could not make these decisions themselves. This review covers advance directives, do-not-resuscitate orders, and POAHC. Figures show an extended values history form, an example of a living will, the California’s Physician Orders for Life-Sustaining Treatment form, components of the CURVES mnemonic to assess decision-making capacity in critical/emergency situations, and activation and deactivation of power of attorney for health care. Tables list the most common types of advance directive and description of each, barriers to the use of advance directives, common themes in surgeons’ attitudes regarding advance directives, general requirements and exclusions for POAHC, and requirements for decision-making capacity in patients. This review contains 5 highly rendered figures, 5 tables, and 56 references

Advance Directives, Do Not Resuscitate Orders, and Power of Attorney for Health Care

2016 ◽  
Author(s):  
Laura Stafman ◽  
Sushanth Reddy
Keyword(s):  
Health Care ◽  
Decision Making ◽  
Advance Directives ◽  
Advance Directive ◽  
Persistent Vegetative State ◽  
Living Will ◽  
Do Not Resuscitate ◽  
Power Of Attorney ◽  
Decision Making Capacity ◽  
Do Not Resuscitate Orders

In 2005, Terri Schiavo collapsed at home and was found by her husband without respirations or a pulse. She was resuscitated, but suffered severe anoxic brain injury and after 21/2 months was diagnosed as being in a persistent vegetative state. A court appointed her husband as her legal guardian as she did not have a written advance directive and had not specified a power of attorney for health care (POAHC), but heated court battles raged between her husband and her parents regarding who should be making decisions and what the appropriate decisions were. This case highlights the importance of writing down instructions for end-of-life care or designating someone to make decisions in their best interest in the event they could not make these decisions themselves. This review covers advance directives, do-not-resuscitate orders, and POAHC. Figures show an extended values history form, an example of a living will, the California’s Physician Orders for Life-Sustaining Treatment form, components of the CURVES mnemonic to assess decision-making capacity in critical/emergency situations, and activation and deactivation of power of attorney for health care. Tables list the most common types of advance directive and description of each, barriers to the use of advance directives, common themes in surgeons’ attitudes regarding advance directives, general requirements and exclusions for POAHC, and requirements for decision-making capacity in patients. This review contains 5 highly rendered figures, 5 tables, and 56 references

Advance Directives, Do Not Resuscitate Orders, and Power of Attorney for Health Care

2016 ◽  
Author(s):  
Laura Stafman ◽  
Sushanth Reddy
Keyword(s):  
Health Care ◽  
Decision Making ◽  
Advance Directives ◽  
Advance Directive ◽  
Persistent Vegetative State ◽  
Living Will ◽  
Do Not Resuscitate ◽  
Power Of Attorney ◽  
Decision Making Capacity ◽  
Do Not Resuscitate Orders

In 2005, Terri Schiavo collapsed at home and was found by her husband without respirations or a pulse. She was resuscitated, but suffered severe anoxic brain injury and after 21/2 months was diagnosed as being in a persistent vegetative state. A court appointed her husband as her legal guardian as she did not have a written advance directive and had not specified a power of attorney for health care (POAHC), but heated court battles raged between her husband and her parents regarding who should be making decisions and what the appropriate decisions were. This case highlights the importance of writing down instructions for end-of-life care or designating someone to make decisions in their best interest in the event they could not make these decisions themselves. This review covers advance directives, do-not-resuscitate orders, and POAHC. Figures show an extended values history form, an example of a living will, the California’s Physician Orders for Life-Sustaining Treatment form, components of the CURVES mnemonic to assess decision-making capacity in critical/emergency situations, and activation and deactivation of power of attorney for health care. Tables list the most common types of advance directive and description of each, barriers to the use of advance directives, common themes in surgeons’ attitudes regarding advance directives, general requirements and exclusions for POAHC, and requirements for decision-making capacity in patients. This review contains 5 highly rendered figures, 5 tables, and 56 references

In My Best Interest

2016 ◽  
Vol 34 (2) ◽  
pp. 160-165 ◽  
Author(s):  
Patricia A. Mayer ◽  
Bryn Esplin ◽  
Christopher J. Burant ◽  
Brigid M. Wilson ◽  
MaryAnn Lamont Krall ◽  
...  
Keyword(s):  
Health Care ◽  
Decision Making ◽  
Medical Center ◽  
Specific Treatment ◽  
Living Will ◽  
Treatment Preferences ◽  
Power Of Attorney ◽  
Best Interest ◽  
Permanent Disability ◽  
Surrogate Decision

Background: Advance directives (ADs) have traditionally been viewed as clear instructions for implementing patient wishes at times of compromised decision-making capacity (DMC). However, whether individuals prefer ADs to be strictly followed or to serve as general guidelines has not been studied. The Veterans Administration’s Advance Directive Durable Power of Attorney for Health Care and Living Will (VA AD) provides patients the opportunity to indicate specific treatment preferences and to indicate how strictly the directive is to be followed. Objective: To describe preferences for life-sustaining treatments (LSTs) in various illness conditions as well as instructions for the use of VA ADs. Design/Setting: A descriptive study was performed collecting data from all ADs entered into the medical record at 1 VA Medical Center between January and June 2014. Measurements: Responses to VA AD with emphasis on health care agents (HCAs) and LW responses. Results: Veterans were more likely to reject LST when death was imminent (74.6%), when in a coma (71.1%), if they had brain damage (70.6%), or were ventilator dependent (70.4%). A majority (67.4%) of veterans preferred the document to be followed generally rather than strictly. Veterans were more likely to want VA ADs to serve as a general guide when a spouse was named HCA. Conclusion: Most of the sampled veterans rejected LST except under conditions of permanent disability. A majority intend VA ADs to serve as general guidelines rather than strict, binding instructions. These findings have significant implications for surrogate decision making and the use of ADs more generally.

On the Edge of Death—To Intervene or Not

2020 ◽  
pp. 33-40
Author(s):  
Alexander Zoretich ◽  
Arvind Venkat
Keyword(s):  
Health Care ◽  
Emergency Department ◽  
Advance Directives ◽  
Medical Condition ◽  
Living Will ◽  
Ethical Challenges ◽  
Power Of Attorney ◽  
Medical Decisions ◽  
Life Sustaining Treatment ◽  
End Stage

Advance directives and actionable medical orders are documents that convey a patient’s wishes regarding medical treatment. Common advance directives are living will and health care power-of-attorney documents. Living wills state what a patient wants if not able to communicate for themselves and having an end-stage medical condition or permanent unconsciousness. Health care powers of attorney state whom a patient would want to make medical decisions on their behalf if not able to communicate for themselves. Both of these documents have minimal application in the emergency department given the time constraints of care in this setting. Actionable medical orders, such as Physician Orders for Life-Sustaining Treatment (POLSTs), have immediate application in the emergency department but carry their own challenges in interpretation by emergency physicians. This chapter reviews the nature of advance directives and actionable medical orders and the legal and ethical challenges posed by their application in the emergency department.

The Impact of Depression on Health Care Decisions

2017 ◽  
Author(s):  
Rebecca Saracino ◽  
Melissa Masterson ◽  
Barry Rosenfeld
Keyword(s):  
Health Care ◽  
Decision Making ◽  
Patient Autonomy ◽  
Future Research ◽  
Health Care Decisions ◽  
Rational Decision Making ◽  
Decision Making Capacity ◽  
Alternative Approaches ◽  
The Impact ◽  
Care Decision

This chapter examines how depression affects health care decisions, with particular emphasis on patient autonomy, capacity, and competence for decision-making. It first considers the ethical boundaries and psycho-legal criteria for assessing decision-making capacity in the context of medical treatment decisions, attending to issues of autonomy and beneficence as well as the debate over whether paternalistic approaches have a place in our health care system. It then discusses the parameters that help define the debate over paternalism, along with the clinical challenges that accompany the assessment and implementation of these alternative approaches to health care decision-making. The chapter also reviews research exploring the impact of depressive symptoms on decision-making capacity and treatment refusal more specifically. It cites the doctrine of informed consent, the goal of which is to promote patient autonomy and rational decision-making. The chapter concludes with recommendations for a comprehensive approach to decision-making capacity assessment and directions for future research.

The Doctor-Proxy Relationship: Perception and Communication

1999 ◽  
Vol 27 (1) ◽  
pp. 13-19 ◽  
Author(s):  
Jomarie Zeleznik ◽  
Linda Farber Post ◽  
Michael Mulvihill ◽  
Laurie G. Jacobs ◽  
William B. Burton ◽  
...  
Keyword(s):  
Health Care ◽  
Decision Making ◽  
Health Care Professionals ◽  
Family Health ◽  
Living Will ◽  
Health Care Decisions ◽  
Medical Interventions ◽  
Incapacitated Patients ◽  
Make Health Care ◽  
Relationship Perception

Health care decision making has changed profoundly during the past several decades. Advances in scientific knowledge, technology, and professional skill enable medical providers to extend and enhance life by increasing the ability to cure disease, manage disability, and palliate suffering. Ironically, the same interventions can prolong painful existence and protract the dying process. Recognizing that medical interventions, especially lifesustaining measures, are not always medically appropriate or even desired by a patient or family, health care professionals endeavor to determine who should make health care decisions and according to what standards. The importance that Western culture places on individual rights and self-determination is reflected in the growing advocacy for patient autonomy and the discrediting of physician paternalism. However, the question of autonomy becomes more complex when patients lack the capacity to decide for themselves.Advance directives represent one response to the dilemma of decision making for incapacitated patients. The original advance directive, the living will, is a written list of instructions reflecting the individual's wishes about care, usually at the end of life.

Health-Care Provider Personal Religious Preferences and Their Perspectives on Advance Care Planning With Patients

2018 ◽  
Vol 35 (12) ◽  
pp. 1565-1571
Author(s):  
Marjorie Bowman ◽  
Sarah St. Cyr ◽  
Adrienne Stolf i
Keyword(s):  
Health Care ◽  
Health Care Providers ◽  
Advance Care Planning ◽  
Religious Affiliation ◽  
Living Will ◽  
Care Planning ◽  
Care Providers ◽  
Power Of Attorney ◽  
Religious Preference ◽  
Advance Care

Objective: To understand how health-care providers’ (HCPs) religious preferences influence their willingness to undertake advance care planning (ACP) with patients and their acceptance of other HCP’s involvement. Methods: Online anonymous survey distributed to HCPs in hospital, ambulatory offices, and hospice settings in Dayton, Ohio. We evaluated the associations of HCP religion with their personal ACP, willingness to facilitate ACP, and acceptance of other HCPs’ ACP participation. Results: 704 respondents: nurses (66.2%), physicians (18.8%), other HCPs (15.0%), white (88.9%), and primarily Catholic (23.3%) or Protestant (32.0%). “No religion” was marked by 13.9%. Respondents were favorable to ACP with patients. Religious respondents were more likely to have a living will ( P = .035) and health-care power of attorney ( P = .007) and more accepting of clergy as ACP decision coaches ( P = .030). HCP’s religion was not associated with willingness to facilitate ACP discussions. There were minor differences between Catholics and Protestants. Conclusions: Personal religious preference is associated with HCP’s own ACP but had little relationship with their willingness to facilitate ACP conversations with patients or acceptance of other professional types of HCPs involvement in ACP conversations. Regardless of religious affiliation, HCPs have interest in undertaking ACP and endorse other HCPs ACP involvement. As results of this study suggest that personal religious affiliation is not a barrier for HCPs engaging in ACP with patients, attempts to overcome barriers to increasing ACP should be directed to other factors.

scholarly journals Engaging Patients in Health Care Decisions in the Emergency Department Through Shared Decision-making: A Systematic Review

2012 ◽  
Vol 19 (8) ◽  
pp. 959-967 ◽  
Author(s):  
Darren Flynn ◽  
Meghan A. Knoedler ◽  
Erik P. Hess ◽  
M. Hassan Murad ◽  
Patricia J. Erwin ◽  
...  
Keyword(s):  
Systematic Review ◽  
Health Care ◽  
Decision Making ◽  
Emergency Department ◽  
Shared Decision Making ◽  
Shared Decision ◽  
Health Care Decisions

Honoring Patient Care Preferences: Surrogates Speak

2012 ◽  
Vol 65 (4) ◽  
pp. 257-280 ◽  
Author(s):  
Julia W. Buckey ◽  
Olga Molina
Keyword(s):  
Decision Making ◽  
Treatment Decision ◽  
Living Will ◽  
Emotional Impact ◽  
Healthcare Team ◽  
Life Sustaining Treatment ◽  
Stressful Experience ◽  
Surrogate Decision ◽  
Interdisciplinary Healthcare ◽  
Interdisciplinary Healthcare Team

A growing body of evidence has pointed to the stressful experience surrounding surrogate decision-making on behalf of incapacitated patients. This study (N = 59) asked surrogates to speak about their experiences immediately after having made a life-sustaining treatment decision. Grounded theory analysis revealed four themes: (1) the emotional impact of the decision-making process on the surrogate; (2) the difficulty of watching a loved one's health deteriorate; (3) the importance of having a Living Will (LW) or other written/verbal instructions; and (4) the reliance on spirituality as a means of coping with the surrogate experience. Findings of this study suggest that engaging surrogates at the time of patient admission may be essential in order to clarify patient preferences and strengthen communication between surrogates and the interdisciplinary healthcare team.

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