Tag: living wills

Bioethics News

Few Americans Plan For End-of-Life Decisions, Even If They Are Sick

Michael S. Dauber, MA, GBI Visiting Scholar

Many moral dilemmas faced by clinicians, patients, and their families arise when individuals have not made plans for the end of their lives or discussed their wishes with their loved ones. To prevent and mitigate these issues, ethicists have suggested for decades that individuals should complete documents such as advanced directives like living wills (legal documents that indicate one’s wishes for interventions like intubation and cardiopulmonary resuscitation (CPR)), and to name a healthcare proxy (an individual to make decisions on one’s behalf in the event one becomes unable). Such measures tend to make it easier for individuals to address moral dilemmas in practice and to determine the ethically appropriate surrogate decision maker for a patient.

According to a recent study published in Health Affairs, few Americans have taken either of these measures. Researchers compiled results from over 150 studies of end-of-life planning measures and determined that only 36.7 percent of those surveyed had completed some sort of advanced directive, with 29.3 percent of those individuals completing living wills and 33 percent empowering a healthcare proxy. The study also found that 42 percent of individuals aged 65 or older had completed some sort of advanced directive, as opposed to 32 percent of individuals younger than 65.

There are several reasons why individuals may be hesitant to complete healthcare proxies. Many young people may feel they can put off decisions about care at the end of their lives because such matters are comparatively unlikely to occur in the short term.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics News

Many Still Sidestep End-Of-Life Care Planning, Study Finds

For the analysis, published in the July issue of Health Affairs, researchers reviewed 150 studies published from 2011 to 2016 that reported on the proportion of adults who completed advance directives, focusing on living wills and health care power-of-attorney documents

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Changing the Paradigm of Advance Directives to Avoid Prolonged Dementia

by Norman L. Cantor In the early days of living wills — the 1970’s and 1980’s – a major objective was to avoid being maintained on burdensome medical machinery in a highly debilitated status at the end stage of a … Continue reading

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics News

Video Messages Clarify Patients’ Wishes for Critical Versus End-of-Life Care

February 17, 2017

(Eurekalert) – Adding a patient-created video testimonial to a living will or “POLST” form can help to prevent errors of interpretation regarding the choice between life-sustaining treatment or allowing natural death in critically ill patients, according to a study in the March Journal of Patient Safety. The journal is published by Wolters Kluwer.  “Interpretation errors are common with living wills and POLST forms,” commented Dr. Ferdinando L. Mirarchi of University of Pittsburgh Medical Center (UPMC) Hamot, in Erie, Pa., lead author of the new report. “Our study shows that medical professionals are more likely to reach a consensus after viewing a video testimonial, proving that we can do better than paper forms alone.”

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

SFEOL – Now Care Planning – Peaceful and Timely Transitions for Patients Who Lack Effective Living Wills

Join me at the next meeting of the San Francisco Bay Area Network for End of Life Care on January 4, 2017, at 11:30 am, at Vintage Golden Gate Fine Arts Hall, 1601 19th Ave, San Francisco, CA 94122.


The topic:  “Now Care Planning – Peaceful and Timely Transitions for Patients Who Lack Effective Living Wills”  


Dr. Stanley Terman will introduce “Now Care Planning”—if the patient’s loved ones are sure that, if the patient could observe her present life and knew her prognosis, she would refuse all life-sustaining treatments—but the patient has either no living will or one that is ineffective. 


This new protocol starts with several people contributing their Substituted Judgment to make treatment decisions on the patient’s behalf. Then they present the treating physician their Consensus of Substituted Judgment. If necessary, they invoke strategies to motivate the physician to honor the patient’s wishes.

“Now Care Planning” strives to attain three goals:
To make the same treatment decision that the patient would have made for his or her current condition, free of self-serving and biased influences.
To reduce the current and future emotional stress of each surrogate decision-maker from making difficult, existential treatment decisions for loved ones.
To motivate treating physicians to honor patient’s end-of-life wishes.

Dr. Terman will explain why Healthcare Professionals might consider training to learn how to counsel patients on “Strategic Advance Care Planning” and “Now Care Planning.” Dr. Terman feels that trained professionals should be adequately compensated for their additional knowledge, experience, and skills. 

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Criteria for When to Override an Advance Directive

Courtenay Bruce and her Baylor colleagues have a useful article in a recent Chest:  “Navigating Ethical Conflicts Between Advance Directives and Surrogate  Decision-Makers’ Interpretations  of  Patient Wishes”


“There is little guidance on what clinicians should do when advance directives (or living wills, specifically) are challenged, particularly when surrogate decision-makers’ interpretations of patients’ wishes conflict with the living will. In our commentary, we make a controversial argument suggesting that overriding living wills can be ethically preferable to the alternative of strictly adhering to them.”


“We propose four ethical considerations for determining whether it is ethically supportable to override living wills.”






















I like this article.  Just as medical guidelines have both false positives and false negatives, so do legal rules.  If we were solely concerned with mitigating the risk of surrogates wrongly overriding the patient’s express advance direction instructions, then we would categorically bar that.  But the harm from such a rule might exceed the benefits, because it would not allow deviations from the advance directive even when warranted.


It might be an interesting project to take a good subset of cases in which courts override advance directives and see if Bruce et al.’s criteria are satisfied.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics News

Bioethical debates. Contributions of religion in the field of research and biomedical practice

As a general rule, bioethical debates deal with the questions raised by scientific-technical breakthroughs in the field of research and biomedical practice. The swiftness with which these advances take place calls into question whether moral philosophy —and in particular theological ethics— can provide answers to the new questions raised, or whether it should capitulate to strategic ethics.

In the last few months, the Journal of Medical Ethics has reignited the debate about the place of religion in medical ethics. Nigel Biggar, Professor of Moral Theology at Oxford University [1], has criticised the moral ambiguity of secular ethics, which often obliges us “to settle for a somewhat messy compromise” [1]. Biggar denies that religious logic is irrational, and admonishes intellectuals to overcome their “scientistic” prejudices and recognise that moral theology is a repository of genuinely convincing and illuminating principles. Biggar’s theory is contested by Kevin Smith, professor at Abertay University in Dundee [2]; Brian Earp, researcher at Oxford University [3]; and Xavier Symons of Sydney Catholic University [4].

Smith’s criticism of Biggar’s arguments centres on the following: firstly, the principles of theological ethics are not universal, since they appeal to divine authority instead of rational discourse; furthermore, they were formulated when the possibilities of contemporary technology for detecting prenatal disease early on, creating and maintaining embryonic life outside the maternal womb, or eliminating intrauterine life using techniques that are safe for the pregnant woman were still unknown. Only “secular” ethics, he adds, guarantee discussion based on ethical principles open to rational analysis. He concludes that only utilitarianism has the potential to attract a universal consensus, because happiness and suffering are, respectively, highly valued and deprecated by all agents who participate in the debate.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Finally, Medicare To Pay for Palliative Care and End-of-Life Care Discussions

On Friday, October 31, 2015, the chief medical officer of
the Centers for Medicare and Medicaid Services announced a final rule which
details
how Medicare will pay practitioners to have conversations with patients
about how they would like to be cared for at the end of life
.
Under the regulation, the patient is not obliged to have these conversations
after a terminal diagnosis is made, or shortly before death is anticipated; the
conversations may take place at any time, even before the patient becomes ill.
The conversation may include discussions about life-sustaining treatments
before they may be necessary, and about advance directives and the
identification and appointment of a legally authorized representative to participate
in the shared decision making progress if the patient were to lose decision
making capacity. The rule, which will take effect in January 2016, creates new
codes for reimbursement under the Medicare physician fee schedule.

It may seem remarkable that there should be any question
about reimbursement for these often-time-sensitive, patient-directed
conversations or discussions at all. But because Medicare payments have
traditionally been tied to physicians completing and documenting finite “tasks”
or “procedures,” these conversations have been “bundled” with other inclusive
duties or responsibilities (such as taking a history or performing a physical
or developing a treatment plan). The idea that Medicare should pay specifically
for the service comes from the belief that if physicians received fairer
compensation for providing the conversation and discussion, they would be
better incentivized to comply. (Of course, this may or may not be the case, since many physicians clearly have
been doing this all along as evidenced by the increased referrals to palliative
care and hospice providers and services over the years.)

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

Medicare’s Proposed Rule Is Just the First Step

As Jane Jankowski, DPS, LMSW discussed in her last AMBI blog posted on June 16, 2015, the proposed rule to reimburse providers for conversations with patients about advance care planning takes a positive step toward educating patients on end-of-life medical considerations by incentivizing doctors to take the time to address these issues in the clinical setting.  Assuming that such reimbursements depend only on raising the topic of advance care planning with patients and not on the content of a patient’s choices (such as whether or not a patient chooses to forego treatment), encouraging health care providers to discuss health care decision making in advance with patients can go a long way to support patient autonomy and provide helpful guidance to surrogate decision-makers when a patient lacks capacity.  Doctors often cite lack of time as a reason why they do not address advance directives in the clinical setting, but this rule would compensate doctors for their time, allowing them more flexibility in allocating time to address these issues.  However, the proposed rule does nothing to ensure that the providers having these conversations are equipped with the proper tools and training to do so.

Advance directives, although they address the provision of medical treatments, are legal documents that can be complex and far-reaching, and therefore are not necessarily self-explanatory to patients or providers.  Many states offer a statutory form advance directive as an example, but all too often these forms may be merely printed by a provider and given to patients to sign without sufficient explanation.  These forms vary in their scope, but some sample living wills, such as forms from West Virginia and South Carolina, are little more than a declaration that no life-sustaining treatments should be provided.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.

Bioethics Blogs

LIVING WILLS, GREYHOUNDS AND GOALPOSTS

National Healthcare Decisions Day – April 16, 2015

By John G. Carney, MEd, President and CEO
Center for Practical Bioethics

For years, I’ve been curious to know whether people fail to complete living wills and avoid naming a healthcare agent out of procrastination or a false sense of confidence that they have plenty of time to do it later.

Reality is, if you don’t do it when you don’t have to, it’s not likely to go well when you do. Naming someone during a time of crisis to speak on your behalf can be downright cruel, especially when you’ve not shared much about the things that are really important to you.

Share What’s Important

What are those things? Well, they aren’t scary or monumental. They include things like how important laughing, talking, sharing and “just being” are to you. Don’t get all tied up in feeding tubes. Instead think about what sharing a meal means to you. Is it a means to an end or an end in itself?

I once shared a house with an older-than-me bachelor and swore when he ate at home he never cooked anything that didn’t come in a box and could go in a microwave. I, on the other hand, started just about every meal sautéing fresh onions and garlic in olive oil. Food had entirely different meanings to us, and that became starkly evident to me when we talked about his dad’s early onset Alzheimer’s and how differently he approached the question of feeding tubes when the difficult question arose in his family.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.