ADVANCE DIRECTIVES PLANNING FOR DYING

PREPARING FOR THE ONSET OF INCAPACITY DEFINITION AND TASK INCAPACITY OCCURS WHEN AN INDIVIDUAL IS UNABLE TO RECEIVE INFORMATION ABOUT HIS/HER CARE, UNDERSTAND AND PROCESS ITS CONTENT, AND COMMUNICATE ABOUT HIS/HER WISHES IN LIGHT OF THE INFORMATION AVAILABLE CLEAR COMMUNICATION DURING THE TIME OF CAPACITY IS THE KEY TO PREPARING FOR A TIME OF INCAPACITY ADVANCE DIRECTIVES ARE TOOLS TO GENERATE COMMUNICATION AND “INSURE” THAT ONE’S WISHES ARE HONORED

TAKING RESPONSIBILITY PLANNING OR VICTIMIZATION LIVING WILL AS ADVANCE DIRECTIVE SURROGATE DECISION MAKERS –GUARDIAN –DURABLE POWER OF ATTORNEY FOR HEALTHCARE AS ADVANCE DIRECTIVE –FAMILY MEMBER TESTS FOR SURROGATE DECISION MAKING –SUBSTITUTED JUDGMENT –BEST INTERESTS

STANDARDS FOR SURROGATE DECISION MAKING SUBSTITUTED JUDGMENT SURROGATE ATTEMPTS TO REPLICATE FAITHFULLY THE DECISION THAT THE INCAPACITATED PERSON WOULD MAKE IF HE/SHE WERE ABLE TO MAKE A CHOICE SURROGATE LOOKS AT THE DECISION THROUGH THE “VALUE EYES” OF THE INCAPACITATED PERSON GROUNDED IN THE PRINCIPLE OF AUTONOMY BASED UPON –DIRECT STATEMENTS BY PATIENT –INFERENCES FROM VALUE CHOICES OF PATIENT SUBSTITUTED JUDGMENT STANDARD IS PREFERABLE BUT BEST INTEREST STANDARD IS PERMITTED AND OFTEN NECESSARY

STANDARDS FOR SURROGATE DECISION MAKING BEST INTERESTS SURROGATE MAKES THE DECISION, FROM AN OBJECTIVE STANDPOINT, WHICH APPEARS TO PROMOTE A PATIENT’S GOOD WITHOUT REFERENCE TO THE INCAPACITATED PATIENT’S ACTUAL OR SUPPOSED PREFERENCES WEIGHING BENEFITS AND BURDENS FROM THE STANDPOINT OF A “REASONABLE” PERSON LOOKING AT THE CLINICAL OUTCOMES –“REASONABLE” = SELF-REFLECTIVE, RELATIVELY UNBIASED, ATTEMPTING FACT-BASED OBJECTIVITY, SETTING ASIDE SELF-INTEREST GROUNDED IN THE PRINCIPLE OF BENEFICENCE

GUARDIANSHIP WHEN PREPARATIONS FOR INCAPACITY ARE NOT MADE AN APPOINTMENT BY THE COURT OF AN INDIVIDUAL WHO WILL MAKE DECISIONS FOR PATIENTS BECAUSE OF THE INCAPACITY (INCOMPETENCE) OF PATIENTS TO MAKE DECISIONS FOR THEIR OWN WELFARE REQUIRES PHYSICIANS TO HONOR THE DECISIONS OF THE GUARDIAN AS THEY WOULD IF THE PATIENTS THEMSELVES HAD MADE THE DECISIONS DISADVANTAGES –TIME-CONSUMING PROCESS –EMOTIONALLY DIFFICULT FOR THE FAMILY –PATIENT MAY BECOMES A VICTIM OF THE GUARDIAN’S AGENDA

ADVANCE DIRECTIVES GENERAL DEFINITION A STATEMENT (WRITTEN OR ORAL) OR THE APPOINTMENT OF A DECISION MAKER MADE BY A PATIENT BEFORE THE ONSET OF DECISIONAL INCAPACITY WHICH INDICATES THE DIRECTION THE PATIENT WOULD LIKE HIS/HER TREATMENT TO TAKE (OR THE INDIVIDUAL WHO SHOULD MAKE SUCH DECISIONS FOR THE PATIENT) WHEN HE/SHE IS NO LONGER ABLE TO PARTICIPATE IN THE HEALTHCARE DECISIONS DIRECTING HIS/HER CARE –STATEMENTS/DOCUMENTS SHOULD STIMULATE COMMUNICATION

ADVANCE DIRECTIVES CENTRAL CHARACTERISTICS SPECIFICITY REGARDING TREATMENTS AND/OR OUTCOMES –CLARITY OF WISHES ABOUT TREATMENTS –CLARITY OF WISHES ABOUT POSSIBLE OUTCOMES –DIFFICULTY IN ACHIEVING SPECIFICITY –RECOMMENDATIONS MINIMALLY ADDRESS CPR/DNR, ARTIFICIAL NUTRITION/HYDRATION, PAIN CONTROL CREDIBILITY REGARDING INTENT AND VALUE CONTEXT –MOTIVATION AND INTENTION OF AUTHOR –BELIEFS OF THE AUTHOR –INSUFFICIENCY OF SIGNATURE ON A FORM