_"Advance Directives" _
By: Claire Danes
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. More aggressive technology approaches are
used to extend the life of the elderly. 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 both 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 workEvaluations
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
living, of course. This is why when the family disagrees with the advance
directive, 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 patients 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.
Word Count: 912
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