Authors: Michelle Blanda, MD, FACEP, Associate Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine/Summa Health System, Akron, OH; Mohan Rajaratnam, MD, Clinical Instructor in Emergency Medicine, Northeastern Ohio Universities College of Medicine/Summa Health System, Akron, OH; John V. Weigand, MD, FACEP, Associate Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine/Summa Health System, Akron, OH.
Peer Reviewer: Catherine A. Marco, MD, Assistant Professor of Emergency Medicine, St. Vincent Mercy Medical Center, Toledo, OH.
The number of elderly patients presenting to the emergency department have increased over the past decade. In 1996, more than one-half million people older than age 65 died in hospitals in the United States.1 These patients often present to the emergency department with catastrophic illness.
The emergency physician must be able to make appropriate and ethical clinical decisions for and with elderly patients. This is especially challenging in settings where no long-term relationship with the patient exists and the time to make a decision is relatively short.2
Discussion of advance directives can be complex and frustrating both for patients and emergency physicians. Frequently, conflicts exist between patient wishes, family choices, and physician recommendations regarding procedures to be performed. These conflicts occur in part because of the wide spectrum of knowledge and preparedness people have for these decisions. This ranges from patients who have discussed their medical wishes and have created detailed documentation concerning their preferences, to those with no plans, previous discussions, or foresight about the issue. In the medically unstable patient, the latter presents a difficult challenge to the emergency physician attempting to provide comprehensive but appropriate and ethical care.
This article defines the types of advance directives commonly used today. Specifically, it discusses the durable power of attorney for health care, the living will, the prehospital advance directive, and the do-not-resuscitate order. The history, ethical principles, and evolution of advance directives during the past two decades will be examined. Factors associated with advance directives and barriers to completion of these orders will be reviewed. The concepts of withholding and withdrawing care will also be discussed. This issue will discuss the concepts of withdrawing and withholding care. Finally, we will address issues of ethical care and decision making, which will assist the emergency physician in managing these difficult scenarios.
— The Editor
Types of Advance Directives
Advance directives are written or oral decisions the patient has made that help guide health care personnel with respect to the patient’s medical treatment in the event the patient loses the ability to make his or her decision known. Three main types of these advance directives are: the durable power of attorney for health care, the living will, and the prehospital directive. There is also a do-not-resuscitate (DNR) order, which is used in a hospital or nursing home setting.
Durable Power of Attorney for Health Care. The durable power of attorney for health care is synonymous with the term medical power of attorney. (See Table 1.) This legal document designates an individual to make decisions for the patient’s future and goes into effect when the patient becomes incompetent or incapacitated. It does not require the patient to be terminally ill. Occasionally, the person may be a guardian appointed by the courts.
| Table 1. Synonymous Names for Different Types of Advance Directives |
| Durable Power of Attorney for Health Care |
| Proxy Directives |
| Medical Power of Attorney |
| Surrogate Decision Maker |
| Health Care Proxy |
| Attorney in Fact |
| Living Will |
| Instructional Directive |
| End-of-Life Care Preferences |
| Do Not Resuscitate Orders |
| No CPR |
| Do Not Attempt Resuscitation (DNAR) |
Living Wills. Living wills are legally recognized documents which delineate the patient’s wishes regarding his or her medical care should they become permanently incapacitated or terminally ill and are unable to speak for themselves. It specifies the patient’s desire to have or to withhold any life-sustaining measures, including nutrition and hydration. In contrast to the durable power of attorney for health care, the living will is seldom used to assist in clinical decision making because it requires the patient be terminally ill, in a coma, or on life support before it can go into effect.3,4 Ideally, a durable power of attorney for health care and a living will are executed together so that the proxy is given specific directions about the patient’s preferences.4,5
Prehospital Advance Directive. The third type of advance directive seen in emergency medicine is the prehospital advance directive (PHAD). This is a standardized form used by an emergency medical service (EMS) region or state.6,7 The PHAD allows EMS providers to withhold unwanted resuscitative efforts even though a "911" call was initiated. This advance directive was designed for adults with terminal diseases. A modification of this advance directive is a prehospital DNR order. These are valid, legal directives expressing the preference of the patient or, if the patient is incapacitated, the proxy’s preference that no heroic measures be attempted to save the patient’s life. A PHAD may be initiated by the patient; however, a prehospital DNR is initiated by the patient’s physician after consultation with the patient or proxy. The prehospital DNR is then given to the patient to keep in his or her possession.
DNR orders may be considered a type of advance directive. DNR orders are valid, legal directives and are used in the hospital long-term care setting. They are theoretically initiated by the patient’s physician after discussion with the patient or proxy, but may be initiated unilaterally based on the physician’s interpretation of the patient’s preferences. If the patient is incapacitated, the proxy may withhold heroic measures to save the patient’s life without prior discussion with the patient. DNR orders previously restricted cardiopulmonary resuscitation in the event of a cardiac arrest. Currently, other elements of medical care, such as transfer to a critical care unit, use of intubation and mechanical ventilation, and use of vasoactive medications and invasive cardiac monitoring such as Swan-Ganz catheters, may be addressed. (See Table 2.)
| Table 2. Forms of Treatment Commonly Addressed in a DNR Order |
| • Cardiac resuscitation |
| • Surgery/Invasive diagnostic tests |
| • Mechanical respiration |
| • Chemotherapy/Radiation |
| • Nutrition/Hydration |
| • Blood/Blood products |
| • Do not hospitalize |
| • Antibiotics |
| • Resuscitative drugs |
| • Dialysis |
Advance directives have state-to-state variability. Not all states recognize every type, but in general they help health care professionals care for patients according to the patients’ predetermined preferences.
Historical Perspectives
Courts, professional organizations, and consumers have advocated that medical decision making, especially for end-of-life decisions, should be guided by the informed preferences and the individual values of the patient. Two historical U.S. Supreme Court cases helped develop and propagate advance directives. These were the Karen Ann Quinlan case in 1976 and the Nancy Cruzan case of 1990.8,9 The Quinlan case gave the parents of a young woman in a vegetative state the right to remove her respirator. Despite this, she did not die until 1985. The Cruzan case involved a 25-year-old woman who had been left in a vegetative state after an auto accident in 1983. A court decision in 1990 gave her parents the right to discontinue nutrition and hydration. These cases set the stage for the use of advance directives throughout the United States.
The decisions from these and other similar cases are based on two fundamental ethical principles that have been used to guide patient care—namely, autonomy and beneficence.3,10,11 Autonomy is respecting the rights of others. In regard to medical care, it allows patients to make decisions about their lives and the treatment they wish to receive. Beneficence refers to "doing good," and in health care, means to restore health and relieve suffering. Traditionally this has been interpreted as providing care directed toward recovery and prevention of complications. It also includes the withdrawal or withholding of treatment based on the assessment of benefit vs. burden.3
Despite these principles and several legal decisions, advance directives remained uncommon. The Patient Self-Determination Act (PSDA) was passed as part of the Omnibus Reconciliation Act of 1990 to address this problem.12 This act was one of a series of federal interventions implemented to promote patient autonomy. It followed other nursing home reforms covering the use of psychotropics and restraints. Unlike previous regulations, the PSDA’s main effect was on education and enhancing the documentation of written advance directives. It was implemented in 1991 and mandated that institutions that receive Medicare and Medicaid federal funds ask patients about the presence of advance directives, record responses, and provide patients lacking such documents with information regarding their right to establish advance directives. It also required institutions to document acceptance or refusal of any life-prolonging treatments in the patient’s chart. Institutions affected include hospitals, skilled nursing facilities, hospices, and health maintenance and health care companies.
The Effect of the Patient Self-Determination Act
Many studies have looked at the effect of the PSDA legislation. Unfortunately, most of these studies found that although there was an increase in the documentation of living wills and durable power of attorney, there was still a large segment of the geriatric population without advance directives.4,13-22 There was also significant variability in the prevalence of advance directives for different segments of the elderly population. For example, in one study reviewing nursing home residents in 10 states, less than one in five residents had an advance directive after the PSDA was initiated.23 Another study showed that only one-third of community-dwelling elderly who were well educated and in good health had advance directives.24 However, most of the advanced directives were for durable power of attorneys for health care.
Although only 12-20% of Americans have completed an advance directive, an overwhelming majority of people have definite opinions regarding resuscitation.25-27 Therefore, even in the absence of an advance directive, communication with patients and families about advance directives and patient preferences prior to, and during, resuscitation attempts is of paramount importance.28-29
The elderly consistently express the desire to make their own health care decisions. A survey of elderly people showed that more than 90% believed the decision for end-of-life choices should be up to them.30 But upon reviewing their advance directives, it was apparent that most had completed a durable power of attorney for health care, which was not accompanied by a living will. In fact, some studies report very high rates of the elderly population with advance directives that possess only a durable power of attorney for health care.31,32 Therefore, very few elderly provide additional instructions for medical care aside from naming a proxy. Most trust and expect family to make treatment decisions if they become incapacitated.30,33-37 This is true even though most elderly people admit to not making their family aware of their wishes. Elderly persons also tend to prefer that a group decision be made by their several family members. This reflects their desire to reduce the burden on any individual family member.33
The number of elderly residents in nursing homes or acute hospital settings with DNR orders has continued to increase to at least half.23,32 Variations in the prevalence of DNR orders in multiple states suggest regional variation.23 One concern with these orders is they may at times be written by the physician without full understanding by or discussion with the patient or his or her family.32
Efforts to improve the situation have been mixed. The Study to Understand Prognosis and Preferences for Outcomes and Risks of Treatment (SUPPORT trial) attempted to increase communication about the hospital’s most seriously ill patients and to aid in benevolent care. Doctors received a prognosis report for each patient and information about the patient’s wishes regarding CPR and advance directives. Nurses were responsible for communication and doctors were responsible for writing DNR orders. The outcomes of this study were disturbing. In 9000 life-threatened patients, there were no significant improvements in the timing of DNR orders, in physician-patient agreement on DNR orders, in the number of undesirable hospital days, in pain control, or in the resources consumed.23,38 However, there have been other studies which did show that different interventions improved the rate of completion of advance directives.39,40
While rates of advance directives have increased, the low overall prevalence of advance directives in the elderly is surprising since more than 90% express support for the idea.19,30 This interesting contradiction seems to suggest that although the elderly population recognizes the importance of advance directives, individuals seem to have personal difficulty with the end-of-life issues. As the proportion of our population older than age 65 steadily increases, the need for these documents will increase as well. The emergency physician plays a pivotal role in educating and encouraging patients to determine and document their choices with respect to life-sustaining medical therapy.41
Factors Associated With the Completion of Advance Directives
Advance directive decision making is a complex process for the geriatric patient. Factors associated with completion of advance directives are listed in Table 3. As people age and develop medical problems, there is a focus on their personal health and preferences regarding advanced medical care. The relationship between perceived health and completion of advance directives is definite. Those patients perceiving themselves as "ill" were significantly more apt to complete advance directives than those who were "healthy." Advance directives had a completion rate of 40-51% when the patients perceived themselves as ill vs. 21-24% when perceived as healthy.42
| Table 3. Factors Influencing Completion of Advance Directives |
| • Previous serious illness of the spouse |
| • Perceived severity of own illness |
| • Single or widowed with regard to marital status |
| • Increasing age |
| • Previous discussion with physician about end-of-life issues |
As a general rule, deteriorating health is usually associated with advancing age.24 Advancing age, especially age older than 75, is strongly associated with increased completion of an advance directive.43 Another strong predictor of having an advance directive was previous serious illness of the spouse. Patients whose spouse had an advanced medical illness were four times more likely to complete an advance directive for themselves.44
Single or widowed people were three times more likely to complete an advance directive than married couples with good family support.44 This was especially true if the patient was widowed after a long marriage, or had no close family members to act as decision makers. These patients realize that decisions may default to more distant family members or perhaps even to a physician with no prior relationship with them.
Interestingly, higher education does not translate into increased likelihood of having completed an advance directive. In fact, in some studies, those who completed college were less likely to have an advance directive than those with far less formal education.24 Race also does not play a significant role in the probability of whether an advance directive will be completed. Numerous studies reveal that when other variables are factored out, the rate of completion of an advance directive is similar for whites, African-Americans, and other ethnic groups.
Barriers to Advance Directives
Certain barriers may continue to negatively impact the widespread use of advance directives. (See Table 4.) The paucity of knowledge about advance directives and an overall misunderstanding of the meaning of these directives are major barriers. Unless the full complexity of advance directives is explained to the patient, they may be misunderstood. A study assessing the knowledge older patients possessed about advance directives indicated a wide misinterpretation of living wills in situations involving a non-terminal illness.45 For example, many patients believed the chance of surviving a cardiac arrest was 70%. Many also believed their advance directives would be useful in an acute illness even though the advance directive specified a terminal state. Additionally, many elements in a living will, including mechanical ventilation, blood transfusions, antibiotics, resuscitative drugs, and medical procedures are not fully understood by the patient and are rarely, if ever, addressed.15 Education not only provides important information, but also assists in comforting the patient and family with the sensitive issues of death and dying.
| Table 4. Barriers to the Use of Advance Directives | |
| • Procrastination | |
| • Lack of previous physician discussion and guidance | |
| • Lack of knowledge/misunderstanding of the components | |
| • Physician is not informed of patient completion | |
| • Cultural beliefs | |
| • Advance directive does not accompany the patient | |
| • Lack of physician compliance with advance directives |
Procrastination and lack of desire to address end-of-life issues by both the physician and the patient create further barriers to the completion of advance directives.46 Prior discussion of advance directives with a physician has a positive influence upon completion of an advance directive, but this often does not occur.42,47,48 There are myriad factors influencing this, including physician and patient discomfort with the issue, lack of time in both the primary care and emergency department settings, and procrastination of these discussions until the patient becomes acutely or terminally ill.45 This is unfortunate, as one study has demonstrated physician involvement increases the rate of completion of an advance directive by three- to fourfold.24
Discussing and planning for end-of-life issues can be an unpleasant experience, one that forces patients to consider their own mortality. It is often difficult for elderly people to transfer their wishes onto a formal health care document. Older people often prefer to deal with difficult issues as they arise, in effect avoiding any decisions until the situation is urgent. Another opinion of elderly patients is that death will be sudden, without a prolonged course of life-sustaining medical treatment. Discussions and decisions with a patient’s family about these issues can also be difficult. Family members are frequently unable to articulate patient treatment preferences. They are often are uncertain about their loved one’s specific wishes or prefer not to be responsible for stopping or withholding medical treatment. Many make decisions that do not conform to their loved ones requests.
Barriers to completing an advance directive may also be related to cultural beliefs. For example, many Hispanic patients feel that advance directives are unnecessary. The reason for this is primarily because of the cultural concept of familism. This concept relates to the importance of family unity and decision making by the family about many issues, including life-sustaining medical care.49
Another interesting barrier is lack of communication. After the patient and his or her family actually complete an advance directive, often with the assistance of an attorney, many fail to inform the physician or nursing home.24 Similarly, the patient may neither keep a copy nor give one to the medical staff. This becomes very important when the patient is urgently transferred to an emergency department setting with no copies of his or her advance directive. Also, many extended care facilities and nursing homes do not send the directives to the emergency department with the patient.50
Finally, multiple reviews suggest that despite the completion of advance directives, many patients still do not discuss them with their extended family or the physician who is caring for them.24 Family members, in their role as surrogate decision makers, and physicians are frequently unable to articulate patients’ treatment preferences.31,33
Ethical Issues
Emergency physicians are frequently the first medical personnel to explain and educate geriatric patients and his or her families about the need for an advance directive. This usually takes place in an urgent discussion, which results from a critically deteriorating status in the elder patient. From an emergency physician’s perspective, saving lives by utilizing a wide variety of advanced medical technologies is a routine part of the specialty. However, acknowledgement of advance directives is just as vital to the patient’s care. The issue of futility is also an element of the decision-making process in caring for the dying patient. Futile care is often defined as medical care given to prolong life when death is imminent. This distinction can be difficult since imminent death is not always clear cut. In addition, there are numerous definitions of "futility" and no consensus among physicians about its definition, meaning, and implications. There are, however, guidelines supporting the physician in withholding or withdrawing care judged to be of unrealistic medical benefit to the patient, even in the absence of an advance directive.51,52 These concepts of withholding or withdrawing care are important for the emergency physician to understand. The influence of emergency medicine training or background and the principles of rapid decision-making and resuscitation may make emergency physicians, in particular, uncomfortable with the idea of withholding care. The concept of withdrawing care also is one not commonly used in an emergency practice.
There is controversy in bioethics and the legal profession about whether withholding medical treatment is equivalent to withdrawing the same treatment. Modern ethicists believe it is neither better nor worse to withdraw treatment than it is to withhold therapy. However, traditionally it has been thought that withholding medical treatment represents a more serious act than withdrawal and that it requires more factual evidence to support withholding.6,9,53
Regardless of the controversy, it is important to remember the concept behind advance directives. This is respect for the patient as an individual (autonomy) and his or her ability to make decisions for his- or herself. In an emergency setting, advance directives should not be implemented without consulting the patient unless the patient lacks decision-making capacity. To determine if the elder patient has capacity for decision making the physician should ensure three points. Does the geriatric patient understand: 1) the treatment options; 2) the consequences of acting on various options; and 3) the risks and benefits of these options in relation to the patient’s values and preferences.54 Disagreement with the physician’s recommendation is not reason for a patient being declared incapacitated.
Unfortunately, the reality of the emergency medicine setting is that it does not allow time for much contemplation. Critically ill patients may be transported by ambulance from their residence before any family members arrive, with the paramedic uncertain if any advance directive exists, or if one does exist, the exact nature of the directive. Other difficult scenarios include transfers from extended care facilities that fail to provide key information, including advance directives. The time required to discover the wishes of the elder patient and his or her family is often the one thing the emergency department physician lacks.
Iserson’s approach to ethical problems in which a decision must be made very quickly is applicable in the emergency setting. This approach applies three tests: the Impartiality Test; the Universalizability Test; and the Interpersonal Justifiability Test.54 The Impartiality Test has the physicians ask if they were in the patient’s situation, would they want this action performed? The Universalizability Test asks whether the practitioner would feel comfortable having all practitioners perform this action in relatively similar circumstances. The Interpersonal Justifiability Test asks whether the practitioner can supply good reasons to other physicians for his or her actions. Can the physician give reasons to his colleagues that would make them understand his rationale? If all three tests can be answered affirmatively, the clinician has a reasonable probability that the intervention falls within the scope of ethically acceptable actions. (See Table 5.)
The Role of the Emergency Physician
Recognition of existing advance directives is very important, but unfortunately can be very challenging in the emergency department. The physician must make life or death decisions very quickly. In the absence of an advance directive, patients with terminal illnesses may be placed on life support and receive treatments they do not desire.
There are many factors that influence medical decision-making. Implied consent is routinely inferred when a patient presents to an emergency department. Medicolegal concerns also may influence the actions taken by the physician. There is the perception that a patient’s family would have wanted "everything" done and might lash out at the emergency physician both emotionally and possibly litigiously if life-sustaining care is withheld. In a busy department, it may seem more expedient to immediately secure a patient’s airway rather than spend time sorting out the patient’s and family’s wishes from an assortment of family members. In addition, a majority of patients desire aggressive care in medically reversible situations.48
These factors contribute to the difficulty in making decisions to withhold care in an emergency setting. This reasoning is also not inconsistent with the concept of withdrawing care since measures instituted during the course of emergency treatment, such as intubation and ventilation, can always be withdrawn at a later time if the family decides. It has been suggested, however, that it is more difficult for family members to withdraw life-sustaining therapy than to institute it in the first place.
The manner in which each emergency physician handles situations such as these often depends on their own practice style, internal value system, and level of comfort with the emotions that arise from these interactions. There is a large continuum of willingness to address future medical decision making in the elderly population. These range from refusal to participate in these decisions to extensive discussions with the patient and family, leading to the signing of an advance directive. This diversity of responses suggests that any education must be as heterogeneous as the population to which it is directed.30
It is important for the emergency physician to initiate these discussions with all elderly patients. Commonly asked questions by elderly people about advance directives are reported in Table 6. This information should be familiar to emergency department staff and be available to elderly patients and their families. Emergency physicians should educate people about future treatment alternatives and decision making in health care. End of life choices need to be discussed more than once.55 Patients need to know emergency physicians are there to educate them and support the decisions they make.
| Table 6. Advance Directive Questions Asked by the Elderly Patient40 |
| Where can advance directive forms be obtained? |
| • Numerous places such as: Doctor's office, agencies on aging, centers for senior health. |
| Who should have a copy of the completed form? |
| • All physicians providing care, family members or significant others, and the patients themselves. |
| Where should the form be kept? |
| • At home, easily located. Should be advised to carry a wallet card stating they have an advance directive, and where it can be found. |
| Will doctors follow patients' wishes? |
| • Advance directives are not initiated unless certain medical criteria are met, such as terminal illness. |
| What if the patient changes his or her mind? |
| • Changes in the document can be easily made, and can be made verbally with careful documentation. |
| Can they choose what they want done or not done, or is it "all or nothing"? |
| • Choices may be made, and particular treatments specified. |
References
1. Graves EJ, Kozak LJ. National Hospital Discharge Survey: Annual Summary 1996. National Center for Health Statistics—Vital and Health Statistics 1999;13.
2. Wrenn K, Brody SL. Do-not-resuscitate orders in the emergency department. Am J Med 1992; 92:129-133.
3. Tasota FJ, Hoffman LA. Terminal weaning from mechanical ventilation: Planning and process. Crit Care Nurs Q 1996;19:36-51.
4. Johnson RF, Baranowski-Birkmeier DO, O’Donnell JB. Advance directives in the medical intensive care unit of a community teaching hospital. Chest 1995;107:752-756.
5. Kjervik DK, Badzek L. Legal considerations at the end of life. AANA Journal 1998;25:593-597.
6. Iserson KV. Nonstandard advance directives: A pseudoethical dilemma. J Trauma 1998;44:139-142.
7. Iserson KV. A simplified prehospital advance directive law. Arizona’s approach. Ann Emerg Med 1993;22:1703-1710.
8. Matter of Quinlan, 70 N.J. 10, 355 A.2d 647 (1976).
9. Cruzan v. Director, Missouri Dept. Of Health, 497 Y.S. 261, 110 S. Ct. 2841 (1990).
10. Raffin TA. Ethics and withdrawal of life support. In: Murray JF, Nadel JA, eds. Textbook of Respiratory Medicine. 2nd ed. Philadelphia, PA: WB Saunders; 1994:2658-2675.
11. Daly BJ, Newlon B, Montenegro HD, et al. Withdrawal of mechanical ventilation: Ethical principles and guidelines for terminal weaning. Am J Crit Care 1993;3:217-223.
12. Patient Self-Determination Act 1991. Omnibus Budget Reconciliation Act of 1990, Public Law #101-508, Secs. 4206, 4751.
13. Miller DK, Lewis LM, Nork MJ, et al. Controlled trial of a geriatric case-finding and liaison service in an emergency department. J Am Geriatr Soc 1996;44:513-520.
14. Teno JM, Licks S, Lynn J, et al. Do advance directives provide instructions that direct care? SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. J Am Geriatr Soc 1997;45:508-512.
15. Goodman MD, Tarnoff M, Slotman GJ. Effect of advance directives on the management of elderly critically ill patients. Crit Care Med 1998;26:701-704.
16. Terry M, Zweig S. Prevalence of advance directives and do-not-resuscitate orders in community nursing facilities. Arch Fam Med 1994;3:141-145.
17. Gregory JJ, Dunn D. Implementation of the Patient Self-Determination Act in a community hospital. N Engl J Med 1995;92:438-442.
18. Jacobson JA, White BE, Battin MP, et al. Patients’ understanding and use of advance directives. West J Med 1994;160:232-236.
19. Palker NB, Nettles-Carlson B. The prevalence of advance directives: Lessons from a Nursing Home. Nurse Pract 1995;20:7-8,13,17-18.
20. Burg MA, McCarty C, Allen WL, et al. Advance directives: Population, prevalence, and demand in Florida. J Fla Med Assoc 1995;82:811-814.
21. Obade C. Patient self determination and advance directive. Arch Intern Med 1995;155:116-117.
22. Park D, Eaton T, Larson E, et al. Implementation and impact of the patient self-determination act. South Med J 1994;87:971-977.
23. Teno JM, Branco KJ, Mor V, et al. Changes in advance care planning in nursing homes before and after the patient Self-Determination Act: Report of a 10-state survey. J Am Geriatr Soc 1997;45:939-944.
24. Gordon NP, Shade SB. Advance directives are more likely among seniors asked about end-of-life care preferences. Arch Intern Med 1999;159:701-704.
25. Broadwell AW, Boisaudin EV, Dunn JK, et al. Advance directives in hospital admissions: A survey of patient attitudes. South Med J 1993;86:165-168.
26. Teno J, Lynn J, Wenger N, et al. Advance directives for seriously ill hospitalized patients. J Am Geriatr Soc 1997;45:508-512.
27. Marco CA, Shears RM. Resuscitation preferences of the general public. Presented at the Society for Academic Emergency Medicine Regional Midwest Research Forum, Ann Arbor, MI; September 1999.
28. Schonwetter RS, Walker RM, Solomon M, et al. Life values, resuscitation preferences, and the applicability of living wills in an older population. J Am Geriatr Soc 1996;44:954-958.
29. Hakim RB, Teno JM, Harrell FE, et al. Factors associated with do-not-resuscitate orders: Patients’ preferences, prognoses and physicians’ judgements. Ann Intern Med 1996;125:284-293.
30. Bailey DJ, DePoy E. Older people’s responses to education about advance directives. Health & Social Work 1995;20:223-228.
31. Teno JM, Licks S, Lynn J, et al. Do advance directives provide instructions that direct care? J Am Geriatr Soc 1997;45:508-512.
32. Levin JR, Wenger NS, Ouslander JG, et al. Life-sustaining treatment decisions for nursing home residents: Who discusses, who decides and what is decided? J Am Geriatr Soc 1999;47:82-87.
33. Miles SH, Koepp R, Weber EP. Advance end-of-life treatment planning. A research review. Arch Internal Med 1996;156:1062-1068.
34. High DM. Families’ roles in advance directives. Hastings Cent Rep 1994;24(suppl 16):S16-S18.
35. High DM. Why are elderly people not using advance directives?
J Aging Health 1993;5:497-515.
36. High DM. Standards for surrogate decision making: What the elderly want. J Long Term Admin 1989;17:8-13.
37. Gamble ER, McDonald PJ, Lichstein PR. Knowledge, attitudes and behavior of elderly persons regarding living wills. Arch Intern Med 1991;151:277-280.
38. Teno J, Lynn J, Wenger N, et al. Advance directives for seriously ill hospitalized patients: Effectiveness with the Patient Self-Determination Act and the SUPPORT intervention. J Am Geriatr Soc 1997;45:500-507.
39. Siegert EA, Clipp EC, Mulhausen P, et al. Impact of advance directive videotape on patient comprehension and treatment preferences. Arch Fam Med 1996;5:207-212.
40. Husted GL, Miller MC, Zaremba JA, et al. Advance directives and what attracts elderly people to particular brochures. J Gerontol Nurs 1997;23:41-45.
41. Iserson KV. Sailing life’s uncharted seas: Advance directives and emergency medicine patients. Acad Emerg Med 1997;4:933-934.
42. Llovera I, Mandel FS, Ryan JG, et al. Are emergency department patients thinking about advance directives? Acad Emerg Med 1997;4:976-980.
43. Hackim RB, Teno JM, Harrell FE Jr., et al. Factors associated with do-not-resuscitate orders: Patients’ preferences, prognoses, and physicians’ judgements. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. Ann Intern Med 1996;125:284-293.
44. Mansell D, Kazis L, Glantz L, et al. Roles of physicians, attorneys, and illness experience in advance directives. Southern Med Journal 1999;92:197-203.
45. Schonwetter RS, Walker RM, Solomon M, et al. Life values, resuscitation preferences, and the applicability of living wills in an older population. J Am Geriatr Soc 1996;44:954-958.
46. Ishihara KK, Wrenn K, Wright SW, et al. Advance Directives in the emergency department: Too few, too late. Acad Emerg Med 1996;3:50-53.
47. Dexter PR, Wolinsky FD, Gramelspacher GP, et al. Effectiveness of computer-generated reminders for increasing discussions about advance directives and completion of advance directive forms: A randomized, controlled trial. Ann Intern Med 1998;128:102-110.
48. Tulsky JA, Fischer GS, Rose MR, et al. Opening the black box: How do physicians communicate about advance directives? Ann Intern Med 1998;129:441-449.
49. Morrison RS, Zayas LH, Mulvihill M, et al. Barriers to completion of health care proxies. Arch Intern Med 1998;158:2493-2497.
50. Morrison RS, Olson E, Mertz RR, et al. The inaccessibility of advance directives on transfer from ambulatory to acute care settings. JAMA 1995;274:478-482.
51. Adams J, Wolfson AB. Ethical issues in geriatric emergency medicine. Emerg Med Clin North Am 1990;8:183-192.
52. Tomlinson T, Brody H. Futility and the ethics of resuscitation. JAMA 1990;264:1276-1280.
46. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 3rd ed. New York, NY: Oxford University Press; 1989:148-150.
47. Iserson KV, Sanders AB, Mathieu D, eds. Ethics in Emergency Medicine. 2nd ed. Tucson, AZ: Galen Press; 1995:44-47.
48. Basile CM. Advance directives and advocacy in end-of-life decisions. Nurse Pract 1998;23:44, 46, 54, 57-60.
Physician CME Questions
17. The Patient Self Determination Act mandates that:
A. all patients have an advance directive on file.
B. federally funded institutions provide information to patients regarding advance directives.
C. in the absence of an advance directive, all terminally ill patients will be given do-not-resuscitate (DNR) status.
D. advance directives must be introduced and documented by the patient’s primary care physician.
18. Medical Power of Attorney is synonymous with:
A. living will.
B. executor of the estate.
C. durable power of attorney for health care.
D. do-not-resuscitate.
19. Living wills:
A. are only valid upon death.
B. delineate the families wishes for the patient if the patient is ill.
C. specify the patient’s desires to have or withhold any life-
sustaining measures.
D. are synonymous with DNR orders.
20. The prehospital advance directive (PHAD):
A. is a non-standardized form used by police agencies.
B. allows EMS providers to not respond to a "911" call.
C. can be initiated by the patient without a physician.
D. was designed for adults with non-terminal diseases.
21. DNR orders:
A. are non-valid legal directives and used in the hospital setting.
B. are helpful to keep the cost of care down.
C. may be initiated unilaterally based on the physician’s interpretation of the patient’s preferences.
D. can only restrict cardiopulmonary resuscitation (CPR).
22. A fundamental, ethical principle used to guide patient care is:
A. autonomy—respecting the rights of others; allowing patients to make decisions about their lives and the treatment they wish to receive.
B. benevolence— "doing good" regardless of cost, complications, or suffering.
C. futile care—a physician must perform medical care to prolong life when death is imminent.
D. withdrawing or withholding care—physicians are given the ability to withdraw or withhold care through implied consent.
23. Which of the following factors is associated with the completion of advance directives?
A. Patient’s perceiving themselves as "ill"
B. Decreasing age
C. Higher level of education
D. Being married
24. Barriers to advance directives include:
A. lack of time with family.
B. worries about funeral expenses.
C. cultural beliefs.
D. too much communication between the patient, family, physician, and extended care facility.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content