Advance Directives - Importance Of Communication

The consideration of an advance directive should be the start of an ongoing discussion among the individual, family members, and the family doctor about end-of-life health care. Discussions about one's advance directive FIGURE 7.3
Advance health-care directive, 1995 need not be limited to treatment preferences and medical circumstances. Sometimes knowing things such as the patient's religious beliefs and values can be important for the proxy when speaking for the patient's interests. The Center for Health Law and Ethics at the University of New Mexico has devised a values questionnaire to help people examine their attitudes about issues related to illness, health care, and dying. It may serve as a valuable tool to guide discussions between the patient and the proxy, as well as among family members.

When preparing an advance directive, it is vitally important for the family and proxy to fully understand the care and measures that are wanted. Even when a patient has a living will calling for no "heroic measures," if the family demands such medical intervention, it is likely that the hospital or doctor will comply with the family's wishes rather than risk a lawsuit if the family demands such medical intervention.

Highlighting the need for communication, a 1998 study of 250 terminally ill patients and their families showed that only 66 percent of the families surveyed accurately predicted the level of treatment their dying family member would want. Researchers from the Georgetown University Center for Clinical Bioethics separately questioned the patient and the patient's likely surrogate about the treatment that the patient would desire in three different end-of-life scenarios. One-third of the surrogates chose differently than the patient, evenly divided between picking too much and too little treatment.

In the Absence of Advance Directives

Physicians usually involve family members in medical decisions when the patient has not designated a health care proxy in advance. Many states have family consent or surrogate consent laws for this purpose. (See Figure 7.4.) Some have laws that designate the order in which family members may assume the role of surrogates or FIGURE 7.3
Advance health-care directive, 1995 decision makers. For example, the spouse may be the prime surrogate, followed by an adult child, then the patient's parent, etc.