ADVANCE DIRECTIVES--PRINCIPLES AND PRACTICE
Lecture Outline
Prepared for Advance Directive Seminar, Batavia, NY, April 22, 1993
Copyright 1996 Robert S. Stall, MD
Available from Dr. Stall's WWW Home Page--Posted January 1, 1996
(http://www.acsu.buffalo.edu/~drstall/index.html)

I.   Ethical Principles

     A.   Patient Autonomy--"Control of one's destiny"
          1.   Informed Consent
          2.   Right to Refuse Treatment
          3.   Right to Request Treatment
          4.   Capacity to Make Decisions
               a.   Memory
               b.   Understanding
                    (Demented patients may be able to make decisions)

     B.   Beneficence--"Obligation to do good"
          Nonmaleficence--"Obligation to avoid harm"
          1.   "Curing" vs. "Healing", "Science" vs. "Art" of medicine
          2.   "Length of life" vs. "Quality of life"
               a.   "Active" life expectancy
               b.   Ability to "understand what others say to me, and
                    respond to them by squeezing a hand, blinking, or by
                    giving some other signal..."
               c.   Ability to "speak or write well enough to hold a
                    conversation..."
               d.   Ability to "leave the hospital and live without being
                    attached to a ventilator or other machines..."
               e.   Ability to "perform...activities that are important to
                    me (for example, reading or washing and dressing
                    myself)..."
          3.   Patient Satisfaction
               (AIM article--"In our opinion, only if the document
               stimulates discussion and communication between patients
               and physicians will the current enthusiasm for advance
               directives be justified.")

     C.   Justice--"Nondescrimination"; "Fair distribution"
          1.   Agist attitudes                    
               (Age sufficient criteria?  What about well 80 yr old and
               chronically ill 40 yr old?  Should "active life expectancy" be
               the important factor?)
          2.   Allocation of  resources, social welfare vs. individual welfare
               (NEJM article--Medicare costs in last year of life)

     D.   Fidelity--"Duty to keep promises"
          1.   Confidentiality
          2.   Accessibility
          3.   Dependability
          4.   Responsivity
          5.   Honesty
          6.   Loyalty
          7.   Advocacy

II.  Role of the Physician

     A.   Good Communication with Patients
          (Medicine at the Crossroads--Code of Silence--WCCH handout)

     B.   Are We Discussing Advance Directives with Patients?
          (JAGS article)

     C.   How to Discuss Advance Directives with Patients
          (Medical Ethics text, Preventive Health Guidelines)
          (Takes time--don't wait until it's too late)
          1.   Specific issues
               a.   CPR
               b.   Artificial ventilation
               c.   Artificial nutrition and hydration
               d.   Treatment of infections and other diseases (e.g.
                    antibiotics, other medications, blood transfusions,
                    dialysis, transplantation)
               e.   Transfers (e.g. to hospital, nursing home)
          2.   Approaches
               a.   "I would like to discuss with you something I discuss
                    with all my patients..."
               b.   "If you could not make health care decisions for
                    yourself, who would you want to make them for you?"
               c.   "If you were too ill to talk to your doctor, who would
                    you like to speak with your doctor regarding medical
                    decisions?
               d.   "Do you have any concerns about dying?"
               e.   "Are there certain conditions that you feel would be a
                    worse state than death?"
               f.   "Some people who have a life-threatening illness
                    would want everything done to save their life.  Others
                    would not want certain treatments or any treatment at
                    all.  How do you feel about this?"
               g.   "Do you know what DNR and Health Care Proxy
                    mean?"

III. Common Dilemmas/Questions

     A.   "DNR" does not mean "Do Not Treat"

     B.   DNR in the OR?
          (NEJM article)

     C.   "Tube feedings or no tube feedings?"

     D.   No advance directives, no relatives, not competent
          (NEJM article--"In March 1992 the NYS Task Force on Life and
          the Law recommended legislation to authorize surrogate decision
          making for incompetent patients")

     E.   ALC DNR--every 60 d renewal (same as nursing facility)

     F.   DNR with active Health Care Proxy--treat Health Care Agent as if
          he/she were the patient

     G.   "The family doesn't want..."--competent patients should be
          allowed to make their own decisions

     H.   Ethics committees--Role in education, clarification, advisement,
          decision-making?  Or just "Passing the buck" (comfort in
          numbers, institutionalization vs. personalization of advance
          directives and ethical decisions)?
           (Hastings Center Ref--Ethics Committees)