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Advance Directives (advance + directive)

Distribution by Scientific Domains

Medical Sciences	69%

Selected Abstracts

EFNS task force on management of amyotrophic lateral sclerosis: guidelines for diagnosing and clinical care of patients and relatives

EUROPEAN JOURNAL OF NEUROLOGY, Issue 12 2005
An evidence-based review with good practice points
Despite being one of the most devastating diseases known, there is little evidence for diagnosing and managing patients with amyotrophic lateral sclerosis (ALS). Although specific therapy is lacking, correct early diagnosis and introduction of symptomatic and specific therapy can have a profound influence on the care and quality of life of the patient and may increase survival time. This document addresses the optimal clinical approach to ALS. The final literature search was performed in the spring of 2005. Consensus recommendations are given graded according to the EFNS guidance regulations. Where there was lack of evidence but consensus was clear we have stated our opinion as good practice points. People affected with possible ALS should be examined as soon as possible by an experienced neurologist. Early diagnosis should be pursued and a number of investigations should be performed with high priority. The patient should be informed of the diagnosis by a consultant with a good knowledge of the patient and the disease. Following diagnosis, the patient and relatives should receive regular support from a multidisciplinary care team. Medication with riluzole should be initiated as early as possible. PEG is associated with improved nutrition and should be inserted early. The operation is hazardous in patients with vital capacity <50%. Non-invasive positive pressure ventilation improves survival and quality of life but is underused. Maintaining the patients ability to communicate is essential. During the entire course of the disease, every effort should be made to maintain patient autonomy. Advance directives for palliative end of life care are important and should be fully discussed early with the patient and relatives respecting the patients social and cultural background. [source]

Advance Directives in Skilled Nursing Facility Residents Transferred to Emergency Departments

ACADEMIC EMERGENCY MEDICINE, Issue 12 2001
Michael Lahn MD
Abstract Objective: Ten years have passed since Congress enacted the Patient Self-Determination Act to promote the use of advance directives (ADs). This study was performed to determine the frequency, type, demographic distribution, and utility of ADs that accompany residents of skilled nursing facilities (SNFs) transferred to emergency departments (EDs). Methods: This was an observational, cross-sectional cohort of SNF residents, transferred to two urban, academic EDs. Chart review and physician interviews were conducted on consecutive patients arriving during 12-hour data collection shifts. Results: Among 715 patients entered, 315 [44%, 95% confidence interval (95% CI) = 40% to 48%] had an AD. Advance directives were significantly more prevalent among white (50%) than African American (34%) or Hispanic (39%) patients (p < 0.001), and varied from 0% to 94% among SNFs. Of the 315 patients with ADs, do-not-resuscitate (DNR) orders were the most prevalent (65%, 95% CI = 58% to 69%). Although 75% (95% CI = 69% to 81%) of the DNR orders addressed cardiopulmonary resuscitation (CPR), only 12% (95% CI = 8% to 16%) addressed intubation. Among 39 patients who required intubation or CPR, 44% had ADs, 82% (95% CI = 57% to 96%) of which were deemed useful. Conclusions: Despite a decade of legislation promoting their use, ADs are lacking in most SNF residents transferred to EDs for evaluation and in most settings in which a clinical indication exists for intubation or CPR. Variation in their prevalence appears to be associated with both ethnicity and SNF origin. Although about three-fourths of DNR ADs addressed CPR, only about one in ten offered guidance regarding intubation. When available, ADs are used in most instances to guide emergency care. [source]

Advance directives and emergency department patients: ownership rates and perceptions of use

INTERNAL MEDICINE JOURNAL, Issue 12 2003
D. McD.
Abstract Background: Advance directives (ADs) are rarely available in Australia to guide management but may become more important as our population ages. Aims: The present study aimed to determine patient knowledge, perception and ownership rates of ADs and the factors that impact upon these variables. Methods: A cross-sectional survey of emergency department patients was undertaken. The main outcome measures were: (i) prior discussion about the extent of medical treatment and ADs, (ii) knowledge and perceptions of ADs, (iii) present AD ownership rates and (iv) likelihood of future AD ownership. Generalized linear models were used for analysis. Results: Four hundred and three patients were enrolled. The mean age of patients was 73 years and 239 (59.3%) were male. Two hundred and forty patients (59.6%) had discussed the extent of treatment. Only 81 patients (20.1%) had discussed the use of an AD. One hundred and thirty-seven patients (34.0%) knew of one type of AD and 333 patients (82.6%) thought some ADs were a good idea. Only 32 patients (7.9%) owned an AD, although 276 (68.5%) would consider owning one. The main reason for never obtaining an AD was ,always wanting full treatment' (93 patients, 23.1%). Level of education was the only characteristic that impacted significantly upon an outcome measure. Patients with a higher level of education were more likely to have known and spoken about ADs, to own an AD and to consider owning one. Conclusions: AD knowledge and ownership rates were low. However, most patients perceive them favourably and many would consider owning one. Intervention strategies to improve AD awareness are indicated. This may empower patients to more effectively participate in their own advance care planning. (Intern Med J 2003; 33: 586,592) [source]

Life-Sustaining Treatments: What Do Physicians Want and Do They Express Their Wishes to Others?

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 7 2003
Joseph J. Gallo MD
OBJECTIVES: To assess whether older physicians have discussed their preferences for medical care at the end of life with their physicians, whether they have established an advance directive, and what life-sustaining treatment they wish in the event of incapacity to make these decisions for themselves. DESIGN: Mailed survey to a cohort of physicians. SETTING: Physicians who were medical students at the Johns Hopkins University in graduating classes from 1946 to 1964. PARTICIPANTS: Physicians who completed the advance directive questionnaire (mean age 68). MEASUREMENTS: Questionnaires were sent out to known surviving physicians of the Precursors Study, an on-going study that began in 1946, asking physicians about their preferences for life-sustaining treatments. RESULTS: Of 999 physicians who were sent the survey, 765 (77%) responded. Forty-six percent of the physicians felt that their own doctors were unaware of their treatment preferences or were not sure, and of these respondents, 59% had no intention of discussing their wishes with their doctors within the next year. In contrast, 89% thought their families were probably or definitely aware of their preferences. Sixty-four percent reported that they had established an advance directive. Compared with physicians without advance directives, physicians who established an advance directive were more likely to believe that their doctors (odds ratio (OR) = 3.42, 95% confidence interval (CI) = 2.49,4.69) or family members (OR = 9.58, 95% CI = 5.33,17.23) were aware of their preferences for end-of-life care and were more likely to refuse treatments than those without advance directives. CONCLUSION: This survey of physicians calls attention to the gap between preferences for medical care at the end of life and expressing wishes to others through discussion and advance directives, even among physicians. [source]

Geriatricians Health Survey 2000

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 11 2001
David Watts MD
OBJECTIVES: To characterize geriatricians' preventive health behaviors including vitamin/supplement use, exercise, smoking, alcohol use, and weight control. DESIGN: Mailed questionnaire. SETTING: United States. PARTICIPANTS: Two thousand six hundred eleven U.S. physicians certified as having added qualifications in geriatric medicine and who were members in the American Geriatrics Society; 1,524 returned completed questionnaires (58%). MEASUREMENTS: Rates of supplement use and recommendations, preventive health visits, advance directive completion, exercise, religious service attendance, smoking, alcohol use, and amount of adult weight gain. RESULTS: Most responding geriatricians took at least one vitamin supplement: 50% vitamin E, 50% a multivitamin (MVI), and 31% vitamin C. Calcium ingestion was common among women. Other supplement use was uncommon: ginkgo compounds were consumed by 47 (3%), and 77 (5%) took a variety of other nonvitamin supplements. Over 90% recommended vitamins, especially multivitamins and vitamin E, at least sometimes. Recommendations for ginkgo (38%) and St. John's wort (33%) were also common. Almost half of respondents had completed a formal advance directive. Exercise was practiced at least weekly by 88%. Cigarette smoking was rare (1%), but at least occasional alcohol use was common (85%). Most of respondents were men (74%), and 35% had completed fellowship training. CONCLUSION: Vitamin/supplement use was common among responding geriatricians but not universal. Respondents often recommended MVI, vitamin E, and vitamin C, but were less likely to consume or recommend other supplements. The most common preventive health behavior among our respondents was exercise. [source]

Medicare Hospital Charges in the Last Year of Life: Distribution by Quarter for Rural and Urban Nursing Home Decedents With Cognitive Impairment

THE JOURNAL OF RURAL HEALTH, Issue 2 2008
Charles E. Gessert MD
ABSTRACT:,Background:Medicare beneficiaries incur 27%-30% of lifetime charges in the last year of life; most charges occur in the last quarter. Factors associated with high end-of-life Medicare charges include less advanced age, non-white race, absence of advance directive, and urban residence. Methods: We analyzed Medicare hospital charges in the last year of life for nursing home residents with severe cognitive impairment, focusing on rural,urban differences. The study population consisted of 3,703 nursing home residents (1,882 rural, 1,821 urban) in Minnesota and Texas who died in 2000-2001. Data on Medicare hospital charges were obtained from 1998-2001 Centers for Medicare and Medicaid Services MedPAR files. Results: During the last year of life, unadjusted charges averaged $12,448 for rural subjects; $31,780 for urban. The charges were distributed across the last 4 quarters similarly for the 2 populations, with 15%-20% of charges incurred in each of the first 3 quarters, and 47% (rural) and 52% (urban) in the last quarter. At the individual level, a higher percentage of hospital charges were incurred in the last 90 days by urban than by rural residents (P < .001). A larger proportion of urban (43%) than rural (37%) residents were hospitalized in the final quarter. The charges for hospitalized residents (N = 1,994) were distributed similarly to those of the entire study population. Discussion: Medicare hospital charges during the last year of life were lower for rural nursing home residents with cognitive impairment than for their urban counterparts. Charges tend to be more concentrated in the last 90 days of life for urban residents. [source]

Advance Refusals of Life-Sustaining Medical Treatment: The Relativity of an Absolute Right

THE MODERN LAW REVIEW, Issue 6 2005
Article first published online: 26 OCT 200, Sabine Michalowski
English law gives the competent patient a right to refuse life-saving treatment, either contemporaneously or in an advance directive. This means that the patient's autonomous choice that in an anticipated situation his/her interests are better served by rejecting life-saving treatment needs to be respected. However, this right is undermined in practice by the courts' approach of applying a presumption in favour of preserving the patient's life whenever the validity and applicability of an advance directive is questioned. The article argues that the patient's right to refuse life-saving treatment only receives the respect it deserves if the decision whether or not a valid and applicable advance directive exists in a given case is instead be approached in an unbiased, disinterested way, and it analyses how this can be achieved in different scenarios. [source]

End-of-Life Decision Making: Practical and Ethical Issues for Health Professionals

AUSTRALASIAN JOURNAL ON AGEING, Issue 2 2000
Colleen Cartwright
Life-extending changes in medical technology and an ageing population pose practical and ethical problems relating to end-of-life decision making. Health professionals need to understand the fears and concerns of their patients, their preferred place to die, and to respect patient autonomy. Such wishes may be expressed verbally by a competent patient or through an advance directive (living will) or proxy by an incompetent patient. There is an urgent need for increased and improved training of health professionals in pain management and palliative care, and for the development of practical, ethical policies and guidelines with respect to withdrawing/withholding life-sustaining treatment. In addition, physician-assisted suicide and euthanasia, two of the important moral issues of the 90s, will continue to require open community debate as we move into the new millennium. Australia, in company with most other countries, has many challenges ahead in relation to end-of-life decision making. [source]

Ethical Issues of Cardiopulmonary Resuscitation: Comparison of Emergency Physician Practices from 1995 to 2007

ACADEMIC EMERGENCY MEDICINE, Issue 3 2009
Catherine A. Marco MD
Abstract Objectives:, The objectives were to determine current practice among emergency physicians (EPs) regarding the initiation and termination of cardiopulmonary resuscitative (CPR) efforts and to compare responses to those from a similar study performed in 1996. Methods:, This anonymous self-administered survey was mailed to 4,991 randomly selected EPs. Main outcome measures included responses regarding current practices related to advance directives and initiation and termination of resuscitative attempts. Results from 1995 and 2007 surveys were compared, using 95% confidence intervals (CIs) of the difference between groups. Results:, Among 928 respondents (18% response rate), most (86%) honor legal advance directives, an increase over 78% reported in 1996 (8% increase, 95% CI = 5% to 11%). Few honor unofficial documents (7%) or verbal reports (12%) of advance directives. Many (58%) make decisions regarding resuscitation because of fear of litigation or criticism. Most respondents (62%) attempt resuscitation in 10% or more of cases of cardiac arrest. A majority (56%) have attempted more than 10 resuscitations in the past 3 years, despite expectations that such efforts would be futile. Factors reported to be "very important" in making resuscitation decisions were advance directives (78%), witnessed arrest (77%), downtime (73%), family wishes (40%), presenting rhythm (38%), age (28%), and prearrest state of health (25%). A significant majority of respondents (80%) indicated that ideally, legal concerns should not influence physician practices regarding resuscitation, but that in the current environment, legal concerns do influence practice (92%). Other than the increase in respondents who honor legal advance directives, these results do not differ substantially from responses in 1996. Conclusions:, Most EPs attempt to resuscitate patients in cardiopulmonary arrest regardless of poor outcomes, except in cases where a legal advance directive is available. Many EPs' decisions regarding resuscitation are based on concerns of litigation and criticism, rather than professional judgment of medical benefit. Most results did not differ significantly from the previous study of 1995, although more physicians honor legal advance directives than previously noted. [source]

END-OF-LIFE CARE IN THE 21st CENTURY: ADVANCE DIRECTIVES IN UNIVERSAL RIGHTS DISCOURSE

BIOETHICS, Issue 3 2010
IREVI, VIOLETA BE
ABSTRACT This article explores universal normative bases that could help to shape a workable legal construct that would facilitate a global use of advance directives. Although I believe that advance directives are of universal character, my primary aim in approaching this issue is to remain realistic. I will make three claims. First, I will argue that the principles of autonomy, dignity and informed consent, embodied in the Oviedo Convention and the UNESCO Declaration on Bioethics and Human Rights, could arguably be regarded as universal bases for the global use of advance directives. Second, I will demonstrate that, despite the apparent consensus of ethical authorities in support of their global use, it is unlikely, for the time being, that such consensus could lead to unqualified legal recognition of advance directives, because of different understandings of the nature of the international rules, meanings of autonomy and dignity which are context-specific and culture-specific, and existing imperfections that make advance directives either unworkable or hardly applicable in practice. The third claim suggests that the fact that the concept of the advance directive is not universally shared does not mean that it should not become so, but never as the only option in managing incompetent patients. A way to proceed is to prioritize work on developing higher standards in managing incompetent patients and on progressing towards the realization of universal human rights in the sphere of bioethics, by advocating a universal, legally binding international convention that would outlaw human rights violations in end-of-life decision-making. [source]

Advance Directives in Skilled Nursing Facility Residents Transferred to Emergency Departments

Interventions to Improve Transitional Care Between Nursing Homes and Hospitals: A Systematic Review

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 4 2010
Michael A. LaMantia MD
Transitions between healthcare settings are associated with errors in communication of information and treatment plans for frail older patients, but strategies to improve transitional care are lacking. A systematic review was conducted to identify and evaluate interventions to improve communication of accurate and appropriate medication lists and advance directives for elderly patients who transition between nursing homes and hospitals. MEDLINE, ISI Web, and EBSCO Host (from inception to June 2008) were searched for original, English-language research articles reporting interventions to improve communication of medication lists and advance directives. Five studies ultimately met all inclusion criteria. Two described interventions that enhanced transmission of advance directives, two described interventions that improved communication of medication lists, and one intervention addressed both goals. One study was a randomized controlled trial, whereas the remaining studies used historical or no controls. Study results indicate that a standardized patient transfer form may assist with the communication of advance directives and medication lists and that pharmacist-led review of medication lists may help identify omitted or indicated medications on transfer. Although preliminary evidence supports adoption of these methods to improve transitions between nursing home and hospital, further research is needed to define target populations and outcomes measures for high-quality transitional care. [source]

Life-Sustaining Treatments: What Do Physicians Want and Do They Express Their Wishes to Others?

Informed Consent and Issues Surrounding Lack of Capacity vs.

JOURNAL OF FORENSIC NURSING, Issue 1 2006
Incompetence
Hospital personnel are often challenged to manage circumstances surrounding a patient's lack of capacity, incompetence, and advance directives. These situations result in undue stress to staff and can be somewhat alleviated by having clear communicaton on policy and law that affect decision-making processes. [source]

Perspectives of Elderly People on Advance Directives in Japan

JOURNAL OF NURSING SCHOLARSHIP, Issue 2 2007
Miho Matsui
Purpose: To examine perspectives of Japanese elderly people on advance directives (ADs) and factors related to positive attitudes toward ADs. Method: The data were collected by a structured questionnaire from 313 of 565 older adult members of senior citizens' centers in two cities in Japan. Survey items pertained to demographic characteristics, terminal care preferences, and personal values, including autonomy, family function, and religious piety. Findings: Of the 313 elderly people who completed questionnaires, 72.9% had positive preferences for executing living wills. With regard to durable power of attorney for health care, 62.2% approved of it. The supporters of ADs were more likely to have had discussions about terminal care with family members or physicians, experience of a family member hospitalized for terminal illness or injury, preferences for life-sustaining treatments that were self-determined, and personal values such as religious piety. The relationship between positive preferences toward durable power of attorney for health care and sex, marital status, and living arrangements were significant. Conclusions: Most Japanese older adults in this study approved of ADs, and family structure was important to the acceptance of designating a proxy. Discussion about end-of-life care and respect for life-sustaining treatment preferences are important decisions, about the end of life. [source]

Rural Bioethical Issues of the Elderly: How Do They Differ From Urban Ones?

THE JOURNAL OF RURAL HEALTH, Issue 4 2001
Jacqueline J. Glover Ph.D.
ABSTRACT: Typical ethical issues in health care for the elderly include decision making for elderly patients with and without capacity, advance directives, the use of life-sustaining technologies, and questions of access to services and justice. Obviously the same issues are relevant for elderly patients in rural settings. But the unique features of rural living add another dimension to ethical discourse and the care of patients, namely the primary importance of relationships. Rural bioethics is based on an ethic of familiarity, which alters our attention to such issues as confidentiality, multiple relationships, scope of practice, and access issues. The following article briefly outlines the unique features of rural bioethics and provides a case analysis. [source]

Ethical Issues of Cardiopulmonary Resuscitation: Comparison of Emergency Physician Practices from 1995 to 2007

Legal implications for failure to comply with advance directives: an examination of the incompetent individual's right to refuse life-sustaining medical treatment

BEHAVIORAL SCIENCES & THE LAW, Issue 3 2002
Sherynn J. Perry
Life-sustaining medical technology in the past century has created a growing body of case law and legislation recognizing the incompetent individual's right to make his or her own end-of-life decisions. This article focuses on California's leadership in the area of these specific end-of-life issues: specifically, exploring the right of an incompetent individual to refuse life-sustaining medical treatment. The article examines advance directives along with various judicial decision-making standards for incompetent individuals and explores the sociobehavioral and legal rationale for compliance with incompetent individual's rights to make end-of-life decisions. Finally this article concludes (i) that advance directives allow competent individuals to state the medical treatment they would prefer in the event they should later become incompetent and (ii) that when advance directives are properly executed in a detailed manner, under laws currently in effect in some jurisdictions, the preferences stated in the directive bind health care providers. Copyright © 2002 John Wiley & Sons, Ltd. [source]

END-OF-LIFE CARE IN THE 21st CENTURY: ADVANCE DIRECTIVES IN UNIVERSAL RIGHTS DISCOURSE

A KOREAN PERSPECTIVE ON DEVELOPING A GLOBAL POLICY FOR ADVANCE DIRECTIVES

BIOETHICS, Issue 3 2010
SOYOON KIM
ABSTRACT Despite the wide and daunting array of cross-cultural obstacles that the formulation of a global policy on advance directives will clearly pose, the need is equally evident. Specifically, the expansion of medical services driven by medical tourism, just to name one important example, makes this issue urgently relevant. While ensuring consistency across national borders, a global policy will have the additional and perhaps even more important effect of increasing the use of advance directives in clinical settings and enhancing their effectiveness within each country, regardless of where that country's state of the law currently stands. One cross-cultural issue that may represent a major obstacle in formulating, let alone applying, a global policy is whether patient autonomy as the underlying principle for the use of advance directives is a universal norm or a construct of western traditions that must be reconciled with alternative value systems that may place lesser significance on individual choice. A global policy, at a minimum, must emphasize respect for patient autonomy, provision of medical information, limits to the obligations for physicians, and portability. And though the development of a global policy will be no easy task, active engagement in close collaboration with the World Health Organization can make it possible. [source]

Factors Affecting Cardiac Catheterization Rates in Elders with Acute Coronary Syndromes

ACADEMIC EMERGENCY MEDICINE, Issue 3 2007
Jin H. Han MD
Background: Elder patients with acute coronary syndromes (ACS) are less likely to receive cardiac catheterization. The reasons for this are unclear. Objectives: To assess whether elder patients who had a documented history of dementia, lived in extended care facilities, or had do not intubate,do not resuscitate (DNR-DNI) advance directives were less likely to receive cardiac catheterization, despite having ACS with high-risk features. Methods: This was a medical record review conducted at an urban teaching hospital. DNR-DNI status before hospitalization, extended care facility (nursing home or assisted living) residence, and a previous diagnosis of dementia were obtained from the medical record. Patients 65 years and older who presented to the emergency department with acute myocardial infarction or with unstable angina with ST segment deviation were included. Univariate and multivariate logistic regression were performed, and odds ratios (ORs) were reported with their 95% confidence intervals (CIs). Results: Of the 201 eligible patients, 66 (32.8%) patients did not undergo cardiac catheterization. In the univariate analysis, patients who had dementia, resided in extended care facilities, or were DNR-DNI were less likely to receive cardiac catheterization. Only extended care facility residence (OR, 0.18; 95% CI = 0.04 to 0.83) and DNR-DNI status (OR, 0.19; 95% CI = 0.04 to 0.92) remained significantly associated with decreased cardiac catheterization in the multivariate analysis. Conclusions: Elder patients with ACS residing in extended care facilities or who are DNR-DNI are less likely to receive cardiac catheterization. Future studies concerning the quality of ACS care for elders should take these variables into account. [source]