Advanced directives

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advanced directives

     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, terminally ill, permanently unconscious or conscious with irreversible brain damage. More aggressive technology approaches are used to extend the life in these cases. 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, advance directives are becoming increasingly prevalent. Advance directives are like living wills. They 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 patients 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.
     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? There is evidence both on the Internet, in case study books and magazines to indicate that advance directives alone fall far short of their objective. In very few cases did advance directives have any influence over decisions to withdraw or withhold life prolonging treatment? The statistics in recent studies demand our attention and make us focus on the tension and disagreement that exists between physicians and their patients. The population clearly seeks more control over their future medical care and also the method, timing, and place of their death. Yet, if one were to really study the publicized statistics, he or she would find that physicians often do not allow patient control. How disheartening for a patient to fear that the doctor cannot be trusted in a matter of such importance.
      It appears that many doctors, nurses, especially manor care takers, have no respect for their patients' wishes. Nurses as patient advocates have a responsibility to make sure patients' wishes are respected; it is nursing's role to raise informed questions and even objections if a patient's treatment violates the patient's wishes. Without strenuous interventions to improve the situation, a vast effort will be put forth to establish something that basically doesn't work. Evaluations of the reasons for the failure to implement a patient's advance directive would show quite a dramatic grab of attention. When families contradict the patients wishes, physicians take their views under consideration giving them immense weight. After all, who does the physician have to answer to? The physician must answer to the living, of course. This is why when the family disagrees with the advance directives; the family's decisions usually win out.      Dealing with death and suffering on a daily basis does not make it easy for medical professionals to make decisions about removing life support. Most make an effort to be as dispassionate as possible about such situations so that families can make informed decisions. Another factor for the failure to follow an advance directive was the treating physician's refusal. One reason for the physician's refusal may be reluctance to acknowledge increasing patient autonomy. After all, the medical decision horizon looks substantially different today than it did just a few years ago. 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 patient's wallet for people to contact, finds a living will card. Nurses can make sure everyone on the health care team knows the document exists, beginning with the physician. Place it in a conspicuous position on the patient's chart and label the chart, if necessary. Nurses in the outpatient setting can educate patients to ask their physicians to make their advance directive part of their medical record, they should keep a copy where it can be found easily and to communicate their wishes clearly to their family and physician and be sure they are understood.
      Providing psychosocial support for patient and family has always been an essential part of medical practice. Nurses may well be trusted in large part because they are presumed to act in defense of their patient’s lives. Nurses give great importance to the psychosocial health of their patients. It is so imperative to be sure and comforted with the idea that a loved one is being taken care of. However, it is when that reassurance is broken with the harsh truth that one's rights have been abused that "the people who help people" are no better than an abuser of one's spirit, trust, and hope, as well.
     It is more likely that the patient’s wishes will be honored if there is a living will in place. To ensure this the patient may want to consider another alternative and along with the living will assign a proxy. A proxy is a person whom the patient has designated to make decisions on their behalf if the patient should be unable to do so. Living wills are not always clear or do not state every situation that may arise. Your proxy will be able to clarify this for you ensuring your wishes will be honored. Be sure that you have discussed your wishes in great detail with them.
     There are several cases in which there have not been advanced directives in place, placing the burden on the family. This leaves room for misinterpretations of your wishes. In one such case Michael Martin "had a tremendous fear of becoming and remaining severely debilitated and disabled, regardless of whether it was mental, physical or both." He discussed this with his wife in great detail. He did not want to be kept alive through the use of machines if he were unable to perform certain tasks. Michael expresses his wishes to his wife and friends on several occasions. Michael was later involved in an accident that "rendered decision ally incapacitated a state he feared. His wife, wanting to respect Michael’s wishes, filed a petition to have him removed from the very machines Michael did not want to sustain his life. When Mary filed this petition Michael mother and sister opposed it and asked that Mary be removed as Michael’s guardian. The court’s ruled against Mary, stating that while she had presented clear and obvious evidence showing that Michael would not want to be sustained, it was not put into writing. Had Michael had advanced directives in place it is more likely that his wishes would have been met.
     
The Legislature passed the Natural Death Act, which allows for living wills, an advance directive to a doctor requesting the withholding or withdrawing of life sustaining treatment. Today, all states have some form of living will legislation. In addition, the individual who wishes to have such a will may also designate a family member or friend as a proxy to make the decisions for him or her should he or she is unable to make the decisions him or herself. Some states also require the individual to sign a power of attorney to do so. In 1976; the New Jersey Supreme Court decided the parents of Karen Ann Quinlan won the right to remove her from a ventilator because she was in a persistent vegetative state. The justices unanimously ruled that this act was necessary to respect Quinlan's right to privacy. Some medical ethicists warned then that the ruling was the beginning of a trend--the slippery slope--which could lead to decisions to end a person's life being made by third parties not only on the basis of medical condition but also on such considerations as age, economic status, or even ethnicity. In 1990, the Supreme Court case, Cruzan v. Missouri, recognized the principle that a person has a constitutionally protected right to refuse unwanted medical treatment. In 1983, Nancy Beth Cruzan lapsed into an irreversible coma from an auto accident. Before the accident, she had said several times that if she were faced with life as a vegetable, she would not want to live. Her parents went to court in 1987 to force the hospital to remove the tube by which she was being given nutrition and water. The Missouri Supreme Court refused to allow the life support to be withdrawn, saying there was no clear and convincing evidence Nancy Cruzan wanted that done. The U.S. Supreme Court agreed, but it also held that a person whose wishes were clearly known had a constitutional right to refuse life-sustaining medical treatment. After further proof and witness testimony, a probate court judge in Jasper County, Mo., ruled Dec. 14, 1990, that Cruzan's parents had the right to remove their daughter's feeding tube, which they immediately proceeded to do. Nancy Cruzan died Dec. 26, 1990.7 The Cruzan decision sparked a fresh interest in living wills and in 1990 Congress passed the Patient Self-Determination Act. It requires health care facilities that receive Medicare or Medicaid funds (95 percent of such centers) to inform new patients about their legal right to write a living will or choose a proxy to represent their wishes about medical treatment, and what kind of measures will be taken automatically for patients as institutional policy. Where state law permits, these institutions must honor living wills or the appointment of a health care proxy.
     To sum it all up it is not just important that you have a living will it is a must. While in the cases of Karen and Nancy their wishes were ultimately met their families had to endure greater pain by petitioning the courts. It is all too sad that Michael wishes were not met and he had to live a life he feared the most. Every individual has the right and responsibility for their own life and decisions and, if they should ever find themselves in a position where their quality of life is threatened by continued medical intervention, they have the right to decide not to receive that treatment. To make this possible in the event that they are unable to do so they should have advanced directives in place and not assume that their families know what to do or that they will respect their wishes as we seen in Michael’s case it does not always hold true.



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