Information to Providers on Advance Directives
It is best to ask your client early on during care if he or she has a living will or other form of advance directive. Not only does this information get included in the client's chart, but by raising the issue, the client has an opportunity to clarify his or her wishes with the care providers and their family. However, advance directives take effect only in situations in which a client is unable to participate directly in medical decision making. Appeals to living wills and surrogate decision makers are ethically and legally inappropriate when individuals remain competent to guide their own care. The assessment of decisional incapacity is often difficult and may involve a psychiatric evaluation and, at times, a legal determination. Some directives are written to apply only in particular clinical situations, such as when the client has a "terminal" condition or an "incurable" illness. These ambiguous terms mean that directives must be interpreted by caregivers. More recent forms of instructive directives have attempted to overcome this ambiguity by addressing specific interventions (e.g., blood transfusions or CPR) that are to be prohibited in all clinical contexts.
What if a client changes his or her mind? Informed decisions by competent clients always supersede any written directive.
What if the family disagrees with a client's living will? If there is a disagreement about either the interpretation or the authority of a client's living will, the medical team should meet with the family to clarify what is at issue. The team should explore the family's rationale for disagreeing with the living will. Do they have a different idea of what should be done? Do they have a different impression of what would be in
the client's best interest given his or her values and commitments? Or does the family disagree with the physician's interpretation of the living will? These are complex and sensitive situations, and a careful dialogue can usually identify many other fears and concerns. However, if the family merely does not like what the client has requested, they do not have much ethical power to sway the team. If the disagreement is based on new knowledge, substituted judgment, or recognition that the medical team has misinterpreted the living will, the family has much more say in the situation. If no agreement is reached, the hospital's ethics committee should be consulted.
How should I interpret a client's advance directive? Living wills generally are written in ambiguous terms and demand interpretation by providers. Terms like "extraordinary means" and "unnaturally prolonging my life" need to be placed in context of the client's values in order to be meaningfully understood. More recent forms of instructive directives have attempted to overcome this ambiguity by addressing specific interventions (e.g., blood transfusions or CPR) to be withheld. The Durable Power of Attorney for Health Care (DPAHC) or a close family member often can help the care team reach an understanding about what the client would have wanted. Of course, physician - patient dialogue is the best guide for developing a personalized advance directive.
What are the limitations of living wills? Living wills cannot cover all conceivable end of life decisions. There is too much variability in clinical decision making to make an all encompassing living will possible. Persons who have written or are considering writing advance directives should be made aware of the fact that these documents are insufficient to ensure that all decisions regarding care at the end of life will be made in accordance with their written wishes. They should be strongly encouraged to communicate preferences and values to both their medical providers and family or surrogate decision makers.
