Advance Medical Directives (cont.)
Siamak N. Nabili, MD, MPH
Dr. Nabili received his undergraduate degree from the University of California, San Diego (UCSD), majoring in chemistry and biochemistry. He then completed his graduate degree at the University of California, Los Angeles (UCLA). His graduate training included a specialized fellowship in public health where his research focused on environmental health and health-care delivery and management.
William C. Shiel Jr., MD, FACP, FACR
Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.
In this Article
- Advance medical directive facts
- Introduction to advance medical directives
- What is the importance of an advance directive?
- What is the history of advance directives?
- The current situation
- When do advance directives become helpful?
- How can one obtain and prepare living will and advance medical directive forms?
The current situation
In the United States, four out of every five adults has no advance directive, a situation that some have likened to taking your car to the mechanic and saying, "I think it needs a tune-up, but if you find something really wrong with it, just go ahead and fix it, even if it won't run afterward? And by the way, please charge me for the work and if I can't pay for it, I'm sure my estate will!"
When asked what would provide a good death, the majority of Americans answer, in essence; "Quick, painless, at home, and surrounded by family."
In 1950, about half of Americans who died did so at home. Now, about 85% of Americans die in a health-care setting: a hospital, a nursing home, or a rehabilitation center. At least 12% die in an intensive-care unit.
Over the past three decades, the United States - all 50 states and the District of Columbia -- have passed laws to legalize the use of living wills, health-care proxies, and/or the durable power of attorney. The U.S. federal government has validated state laws on advance directives through the 1991 Patient Self- Determination Act. And the U.S. Supreme Court has handed down an opinion acknowledging the congruence of the Constitution of the United States with state laws on the right to designate future medical treatment.
When do advance directives become helpful?
Advance directives become active when a patient is no longer able to make his/her own health-care decisions or becomes mentally incapacitated. Until such point is reached, the patient is the ultimate decision maker regarding their health.
Some common scenarios where these directives can help with the decision making process are
- persistent vegetative state,
- severe brain injury,
- advanced Alzheimer's disease or other forms of dementia,
- critical medical illness affecting mental capacity.
Advance directives not only help with decision-making in times of incapacity, but they can also clarify one's preferences during times of uncertainties while still cognitively intact. At times, deciding whether to accept or decline a treatment may overwhelm a person and cast uncertain on their judgment. By referring to previously delineated preferences based on overall goals of care, such decisions may become simpler to make as smaller components of a bigger picture.
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