An advance directive is a legal document that individuals can have prepared describing their health-care wishes in case they become incapacitated due to injury, disease or mental health issues. Advance directives are more commonly known under names such as “living wills.”
The laws allowing advance directives were originally created to address a perceived difference between the wishes of health-care providers and patients. Most health-care providers try to provide care and save lives at all costs, and many patients object vehemently to being subjected to forms of health care that seem to only briefly extend low-quality life.
Physicians confused?
However, surveys of physicians indicate a lot of confusion about advance directives. For example, many surveys report that 44% to 80% of physicians incorrectly think that the mere existence of a living will means that the patient has a Do Not Resuscitate (DNR) order in place.
Additionally, around 20% of physicians report that they would attempt resuscitation even if a DNR order was in place. This type of confusion can lead to unnecessary deaths and also to undesirable medical interventions.
A DNR order is a specific advance directive stating that if the individual is found with no pulse but not yet legally dead, resuscitation should not be attempted. Individuals with terminal illnesses are those most likely to request a DNR order as they would prefer to die with dignity instead of having the process prolonged by technology.
Many living wills and advance directives do not ask for DNRs. A healthy middle-aged person may very well have a living will stating that in the case of brain death life should not be prolonged artificially. This same person might be horrified to learn that physicians may believe the mere presence of this living will means that they should not attempt to resuscitate the patient after a car crash or heart attack causes temporary cardiac arrest. Some health-care providers mistakenly think that the presence of a DNR means to not treat a patient at all.
Too much/ too little medical care
Of complaints involving medical care conflicting with advance directives, only 20% involve patients or patient family members complaining about patients receiving unwanted interventions. The other 80% revolve around patients not receiving wanted interventions due to confusion about advance directives and what they mean. Confusion about advance directives often leads to malpractice lawsuits.
Lack of communication
One major cause of the confusion about advance directives is that attorneys and the law dictate the language used in these documents, and the physicians may not understand the legal language. Another problem is that often the legal documents are locked away and are never seen by medical personnel.
Even if the patient’s primary physician is aware of the advance directive, that does not mean that other health-care providers, such as emergency room physicians or paramedics, will automatically be aware of the document. The increased use of electronic health records may improve awareness of advanced directives.
Another legal twist is that health-care providers can legally refuse to follow the instructions provided in an advance directive under the “conscience” objection clause if they feel an advanced directive is medically inappropriate.
It is important for patients to discuss their advance directives and wishes with their health-care providers. Providing the physician with a copy of your living will and discussing with the physician what you want is one way to avoid misunderstandings. Electronic health records that will alert emergency rooms and nursing homes regarding your wishes may also help raise awareness. Better education of health-care providers about advance directives is also clearly needed.
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