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The Dangers of Directives or the False Security of Forms

Published online by Cambridge University Press:  01 January 2021

Extract

During the past several years, numerous studies have been conducted regarding advance directives (that is, living wills and durable powers of attorney (DPAs) for health care). Studies have examined how many individuals have executed advance directives, who is more likely to execute such directives, and whether factors such as education, income, race, religiosity, or family status affect the likelihood of having executed an advance directive or one's willingness to do so. Studies have also investigated the effectiveness of different educational strategies aimed at increasing the number of individuals who execute these documents. Finally, a number of researchers have looked at the implementation of advance directives (that is, whether they are followed in the institutional setting).

Although we now have a better understanding of some of these issues, one area that has been virtually ignored is the reliability, validity, and overall user friendliness of the advance directive forms themselves, and, in particular, of the statutory advance directive forms.

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Article
Copyright
Copyright © American Society of Law, Medicine and Ethics 1996

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References

Sachs, G.A. Stocking, C.B. Miles, S.H., “Empowerment of the Older Patient? A Randomized, Controlled Trial to Increase Discussion and Use of Advance Directives,” Journal of the American Geriatric Society, 40 (1992): 269–73; Devor, M. et al. , “Compliance with Social and Safety Recommendations in an Outpatient Comprehensive Geriatric Assessment Program,” Journal of Gerontology, 49 (1994): M168–M173; and Emanuel, L.L. Emanuel, E.J., “Decisions at the End of Life: Guided by Communities of Patients,” Hastings Center Report, 23, no. 5 (1993): 6–14.CrossRefGoogle Scholar
Lurie, N. et al. , “Attitudes Toward Discussing Life Sustaining Treatments in Extended Care Facility Patients,” Journal of the American Geriatric Society, 40 (1992): 1205–08; and Sachs, G., “Increasing the Prevalence of Advance Care Planning,” Hastings Center Report, 24, no. 6 (1994): S13–S16.CrossRefGoogle Scholar
Robinson, M.K. DeHaven, M.J. Koch, K.A., “Effects of the Patient Self-Determination Act on Patient Knowledge and Behavior,” Journal of Family Practice, 37 (1993): 363–68.Google Scholar
Robinson, DeHaven, Koch, , supra note 3; and Times Mirror Center for People and the Press, Reflections of the Times: The Right to Die (Washington, D.C.: Times Mirror Center for People and the Press, 1990).Google Scholar
High, D., “Who Will Make Health Care Decisions for Me When 1 Can't?,” Journal on Aging and Health, 2 (1990): 291309; and Cohen-Mansfield, J. et al. , “The Decision to Execute a Durable Power of Attorney for Health Care and Preferences Regarding the Utilization of Life Sustaining Treatments in Nursing Home Residents,” Archives of Internal Medicine, 151 (1991): 289–94.CrossRefGoogle Scholar
Cohen-Mansfield, et al. , supra note 7; Hare, J. Nelson, C.C., “Will Outpatients Complete Living Wills? A Comparison of Two Interventions,” Journal of General Internal Medicine, 6 (1991): 4146; High, D.M., “Advance Directives and the Elderly: A Study of Intervention Strategies to Increase Use,” Gerontologist, 33 (1993): 342–49; and Luptak, M.K. Boult, C., “A Method for Increasing Elders' Use of Advance Directives,” Gerontologist, 34 (1994): 409–12.Google Scholar
The SUPPORT Principal Investigators, “A Controlled Trial to Improve Care for Seriously Ill Hospitalized Patients: The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT),” JAMA, 274 (1995): 1591–98; Danis, M. et al. , “A Prospective Study of Advance Directives for Life Sustaining Care,” N. Engl. J. Med., 324 (1991): 882–88; Danis, M., “Following Advance Directives,” Hastings Center Report, 24, no. 6 (1994): S21–S23; and Morrison, R.S. et al. , “The Inaccessibility of Advance Directives on Transfer from Ambulatory to Acute Care Settings,” JAMA, 274 (1995): 478–82.Google Scholar
Sachs, , supra note 2; and Evans, S. Clarke, P., “Rethinking How We Communicate About Advance Directives: Hidden Errors in Our Assumptions About Planning for Care,” in Communications and the Patient Self-Determination Act: Strategies for Meeting the Educational Mandate; A Resource Guide (Washington, D.C.: Annenberg Washington Program, 1993): 2027.Google Scholar
Patient Self-Determination Act 42 U.S.C. §§ 1395cc, 1396a (1994).Google Scholar
The exceptions are Delaware, New Jersey, and Ohio.Google Scholar
ABA Commission on Legal Problems of the Elderly, “Health Care Power of Attorney Legislation as of Jan. 1, 1996” (unpublished document). These states include Colorado, Delaware, Louisiana, Massachusetts, Michigan, New Jersey, South Dakota, Washington, and Wyoming. In addition, Indiana, Ohio, and Tennessee do not have statutory forms but require that a DPA for health care include specified statutory language. See Ind. Code § 16-36-1-14 (1993) (incorporating § 30-5-5-17 by reference); Ohio Rev. Code Ann. § 1337.17 (Baldwin 1993); and Tenn. Code Ann. §§ 34-6-203, −205 (1991 & Supp. 1995).Google Scholar
ABA Commission on Legal Problems of the Elderly, supra note 13. Ariz. Rev. Stat. Ann. § 36–3224 (Supp. 1995); Fla. Stat. ch. 765.203 (Supp. 1996) (DPA form allows special instructions); Ky. Rev. Stat. Ann. § 311.625 (Baldwin 1995); Me. Rev. Stat. Ann. tit. 18-A, § 5–804 (West Supp. 1995); Md. Code Ann., Health-Gen. § 5–603 (Supp. 1995); N.M. Stat. Ann. § 24–7A-4 (Michie Supp. 1994); Okla. Stat. tit. 63, § 3101.4 (Supp. 1996); Or. Rev. Stat. § 127.531 (Supp. 1994); and Va. Code Ann. § 54.1–2984 (Michie 1994).Google Scholar
Hoffmann, D.E., “The Maryland Health Care Decisions Act: Achieving the Right Balance,” Maryland Law Review, 53 (1994): 1064–130.Google Scholar
Emanuel, L.L. Emanuel, E.J., “The Medical Directive: A New Comprehensive Advance Care Document,” JAMA, 261 (1989): 3288–93. The Medical Directive includes four hypothetical clinical scenarios. For each scenario, twelve possible medical interventions are listed. Thus, someone completing the directive is asked to make forty-eight hypothetical clinical judgments.CrossRefGoogle Scholar
Brett, A.S., “Limitations of Listing Specific Medical Interventions in Advance Directives,” JAMA, 266 (1991): 825–28. Brett argues that the selection of medical interventions out of true clinical context is unrealistic and may not accurately convey a person's true wishes.CrossRefGoogle Scholar
Mower, W.R. Baraff, L.J., “Effect of Type of Directive on Physicians' Therapeutic Decisions,” Archives of Internal Medicine, 153 (1993): 375–81.CrossRefGoogle Scholar
Alaska Stat. § 18.12.010 (1994); Ariz. Rev. Stat. Ann. § 36–3224 (Supp. 1995); Colo. Rev. Stat. § 15-18-104 (Supp. 1994); Conn. Gen. Stat. § 19A-575 (Supp. 1995); Ga. Code Ann. § 31-32-3 (Supp. 1995); Haw. Rev. Stat. §§ 551D-2.6, 327D-4 (1993); Idaho Code §§ 39–4504, −4505 (1993); Ill. Ann. Stat. ch. 755, para. 45/4–10 (1991); Ind. Code §§ 16-36-4-10, −11 (1993 & Supp. 1995); Ky. Rev. Stat. Ann. § 311.625 (Baldwin 1995); Me. Rev. Stat. Ann. tit. 18-A, § 5–804 (West Supp. 1995); Md. Code Ann., Health-Gen. § 5–603 (Supp. 1995); Nev. Rev. Stat. §§ 449.610, -.613, -.830 (Supp. 1995); N.H. Rev. Stat. Ann. §§ 137-H:3, -J:15 (Supp. 1995); N.M. Stat. Ann. § 24–7A-4 (Michie Supp. 1995); N.C. Gen. Stat. § 90–321 (1993); N.D. Cent. Code § 23–06.4–03 (Supp. 1995); Okla. Stat. tit. 63, § 3101.4 (Supp. 1996); Or. Rev. Stat. § 127.531 (Supp. 1994); 20 Pa. Cons. Stat. Ann. § 5404 (Supp. 1995); S.C. Code Ann. §§ 44-77-50, 62-5-504 (Law. Co-op. Supp. 1995); S.D. Codified Laws Ann. § 34–12D-3 (1994); Tenn. Code Ann. § 32-11-105 (Supp. 1995); Vt. Stat. Ann. tit. 14, § 3466 (1989); Wash. Rev. Code § 70.122.030 (Supp. 1996); and Wis. Stat. §§ 154.03, 155.30 (Supp. 1995).Google Scholar
While most DPAs provide space for individuals to write in specific instructions that they want their agents to follow or that limit their agents' authority, forms that simply provide this type of option were not included in this tally.Google Scholar
These states include Hawaii (Haw. Rev. Stat. §§ 551D-2.6, 327D-4 (1993)), Nevada (Nev. Rev. Stat. §§ 449.610, -.613, -.830 (Supp. 1995)), New Hampshire (N.H. Rev. Stat. Ann. §§ 137-H:3, -J: 15 (Supp. 1995)), and South Carolina (S.C. Code Ann. §§ 44-77-50, 62-5-504 (Law. Co-op. Supp. 1995)).Google Scholar
See Alaska Stat. § 18.12.010 (1994); Colo. Rev. Stat. § 15-18-104 (Supp. 1994); Haw. Rev. Stat. §§ 551D-2.6, 327D-4 (1993); Ind. Code § 16-36-4-10 (Supp. 1995); and Wash. Rev. Code § 70.122.030 (Supp. 1996). The Colorado Declaration as to Medical or Surgical Treatment allows an individual to state the number of days that artificial nourishment is to be provided. Colo. Rev. Stat. § 15-18-104 (Supp. 1994).Google Scholar
N.D. Cent. Code § 23–06.4–03 (Supp. 1995).Google Scholar
See, for example, Nev. Rev. Stat. §§ 449.610, -.613, -.830 (Supp. 1995).Google Scholar
In Nevada, an individual must initial the following statement if he/she wants artificial nutrition or hydration: “Withholding or withdrawal of artificial nutrition and hydration may result in death by starvation or dehydration. Initial this box if you want to receive or continue receiving artificial nutrition and hydration by way of the gastro-intestinal tract after all other treatment is withheld pursuant to this declaration.” Nev. Rev. Stat. § 449.610 (Supp. 1995).Google Scholar
Terminal illness, however, is defined differently from state to state. See Alaska Stat. § 18.12.010 (1994) (limiting application of form to “incurable or irreversible condition[s] that will cause... death in a relatively short time”); Colo. Rev, Stat. § 15-18-104 (Supp. 1994) (restricting form's application to injuries, diseases, or illnesses that are “not curable or reversible and which [are] a terminal condition” defined as “an incurable or irreversible condition for which the administration of life-sustaining procedures will serve only to postpone the moment of death.”); Ind. Code §§ 16-36-4-10, −11 (1993 & Supp. 1995) (providing for form's use on physician's certification of incurable injury, disease, or injury from which death will occur in a short time); Nev. Rev. Stat. §§ 449.610, -.613 (Supp. 1995) (same, except it does not require physician's certification); N.D. Cent. Code § 23–06.4–03 (Supp. 1995) (requiring two physicians' certification of “incurable or irreversible condition” that “will result in … imminent death”); and Tenn. Code Ann. § 32-11-105 (Supp. 1995) (limiting form's use to terminal condition, defined as “any disease, illness, injury or condition, including, but not limited to, a coma or persistent vegetative state, sustained by any human being, from which there is no reasonable medical expectation of recovery and which, as a medical probability, will result in the death of such human being, regardless of the use or discontinuance of medical treatment implemented for the purpose of sustaining life, or the life processes.”).Google Scholar
See Conn. Gen. Stat. § 19a-575 (Supp. 1995); Idaho Code § 39–4504 (1993); Ky. Rev. Stat. Ann. § 311.625 (Baldwin 1995); Me. Rev. Stat. Ann. tit. 18-A, § 5–804 (West Supp. 1995); N.M. Stat. Ann. § 24–7A-4 (Michie Supp. 1995); 20 Pa. Cons. Stat. § 5404 (Supp. 1995); and Wash. Rev. Code § 70.122.030 (Supp. 1996).Google Scholar
See Ariz. Rev. Stat. Ann. § 36–3262 (Supp. 1995); Ga. Code Ann. § 31-32-3 (Supp. 1995); N.H. Rev. Stat. Ann. § 137-J:15 (Supp. 1995); N.C. Gen. Stat. § 90–321 (1993); Okla. Stat. tit. 63, § 3101.4 (Supp. 1996); S.C. Code Ann. § 44-77-50 (Law. Co-op. Supp. 1995); and Wis. Stat. § 154.03 (Supp. 1995).Google Scholar
Md. Code Ann., Health-Gen. § 5–603 (Supp. 1995).Google Scholar
Or. Rev. Stat. § 127.531 (Supp. 1994).Google Scholar
20 Pa. Cons. Stat. § 5404 (Supp. 1995).Google Scholar
See Ariz. Rev. Stat. Ann. § 36–3262 (Supp. 1995); Ga. Code Ann. § 31-36-10 (1991); Ill. Ann. Stat. ch. 755, para. 45/4–10 (Smith-Hurd 1991); Ind. Code § 16-36-4-11 (1993); Me. Rev. Stat. Ann. tit. 18-A, § 5–804 (West Supp. 1995); Md. Code Ann., Health-Gen. § 5–603 (Supp. 1995); Nev. Rev. Stat. § 449.830 (Supp. 1995); N.M. Stat. Ann. § 24–7A-4 (Michie Supp. 1995); N.D. Cent. Code § 23–06.4–03 (Supp. 1995); Or. Rev. Stat. § 127.531 (Supp. 1994); S.C. Code Ann. § 62-5-504 (Law. Co-op. Supp. 1995); and S.D. Codified Laws Ann. § 34–12D-3 (1994).Google Scholar
See Ga. Code Ann. § 31-36-10 (1991); Ill. Ann. Stat. ch. 755, para. 45/4–10 (Smith-Hurd 1991); Nev. Rev. Stat. § 449.830 (Supp. 1995); and S.C. Code Ann. § 62-5-504 (Law. Co-op. Supp. 1995).Google Scholar
S.C. Code Ann. § 62-5-504 (Law. Co-op. Supp. 1995).Google Scholar
See Me. Rev. Stat. Ann. tit. 18-A, § 5–804 (West Supp. 1995); Md. Code Ann., Health-Gen. § 5–603 (Supp. 1995); and N.M. Stat. Ann. § 24–7A-4 (Michie Supp. 1995).Google Scholar
Uniform Health Care Decisions Act § 1–19, 9 U.L.A. 201 (Supp. 1995).Google Scholar
Me. Rev. Stat. Ann. tit. 18-A, § 5–804 (West Supp. 1995); and N.M. Stat. Ann. § 24–7A-4 (Michie Supp. 1995).Google Scholar
Md. Code Ann., Health-Gen. § 5–601 to −608 (1993 & Supp. 1995).Google Scholar
Uniform Health Care Decisions Act § 4, 9 U.L.A. 207 (Supp. 1995).Google Scholar
Veterans Administration Form 10–0137C (Nov. 1991).Google Scholar
Memo from Charles Sabatino, ABA Commission on Legal Problems of the Elderly, to Diane E. Hoffmann, Esq., University of Maryland Law School (July 7, 1995).Google Scholar
David, T.C. et al. , “The Gap Between Patient Reading Comprehension and the Readability of Patient Education Materials,” Journal of Family Practice, 31 (1990): 533–38.Google Scholar
Emanuel, L.L. et al. , “Advance Directives: Stability of Patients' Treatment Choices,” Archives of Internal Medicine, 154 (1994): 209–18.CrossRefGoogle Scholar
Sehgal, A. et al. , “How Strictly Do Dialysis Patients Want Their Advance Directives Followed?,” JAMA, 267 (1992): 5963.Google Scholar
Wetle, T., “Individual Preferences and Advance Directives,” Hastings Center Report, 24 (1994): S55S58.Google Scholar
Forrow, L., “The Green Eggs and Ham Phenomena,” Hastings Center Report, 24 (1994): S29S32.CrossRefGoogle Scholar
Emanuel, E.J. Emanuel, L.L. Orentlicher, D., letter, “Advance Directives,” JAMA, 266 (1991): 2563.Google Scholar