Advanced Directives
Definition
Advance directives provide individuals with a method to identify their health care preferences for the event that they become incompetent to make such decisions in the future. There are two major groups of advance directives: instructional and proxy directives. Instructional directives allow an individual to identify what or how health care decisions are to be made if they become incompetent (Senate of Canada, 1995). Instructional directives are at times referred to as living wills, end-of-life instructions or treatment directives. Proxy directives allow individuals to specify who is to make health care decisions in the event that they become incompetent (Senate of Canada, 1995). Proxy directives are at times referred to as power of attorney for health care, mandate for health care, appointment directives, substitute decision maker for health care or personal directive agent.
An advance directive only comes into effect when an individual is incompetent to make health care decisions. A competent individual can change, negate or destroy their advance directive at any time. The majority of advance directives are used to instruct health care professionals to withdraw or withhold medical treatments such as cardiopulmonary resuscitation, mechanical ventilation, dialysis, antibiotics, surgery, invasive diagnostic procedures, or artificial nutrition and hydration. However, advance directives may also be used to request medical treatment. Many different formats of advance directives are currently available in Canada. It has been recommended that a combined document which includes both a living will and power of attorney for health care would provide the best assurance that critical care patient's desires concerning medical treatment will be respected (Silverman et al. 1992). Decision-making should be informed: consultation with health care professionals is seen as beneficial in helping individuals make an informed decision.
Background
Advances in medical technology now permit the extensive use of life-sustaining treatments. However, not all individuals want to receive life-prolonging therapies for every health crisis. Critically ill patients are often unconscious or incompetent to indicate their treatment preferences. Advance directives promote patient autonomy and self determination by allowing individuals to identify their preferences regarding life-sustaining treatment for the event that they become incapable of expressing such wishes themselves. Advance directives also provide a framework to facilitate discussions about life sustaining treatments and end of life decision making between patients, family members or significant others, and the health care team. The ideal time for discussions about advance directives is before a health care crisis occurs. Both the Canadian Nurses Association (1994) and Canadian Medical Association (1992) support the concept of advance directives. Values from the Canadian Nurses Association Code of Ethics for Registered Nurses (1997), which are relevant to the topic of end of life decision making and advance directives include health and well-being, choice, and dignity (Canadian Nurses Association, 1998).
While the issue of advance directives has not been directly addressed in Canadian courts, some Canadian court decisions support the concept of advance directives (Sneiderman, 1991). It has been recommended that all Canadian provinces implement legislation related to advance directives (Senate of Canada, 1995). As legislation in each province can vary, critical care nurses should ensure that they are familiar with their current provincial legislation. However, lack of provincial legislation does not inherently negate the validity of an advance directive.
Research
A 1997 survey conducted at the Canadian Association of Critical Care Nurses (CACCN) national conference found that 80% of respondents had cared for at least one patient with an advance directive and that 89% of respondents were in favor of advance directives (Leith, 1998). Previous research with Canadian physicians and nurses also found that the majority favored the use of advance directives in clinical care (Hugues & Singer, 1992; Kelner, et al., 1993). While research suggests that the Canadian general public supports the use of advance directives (Molloy et al., 1991; Storch & Dossetor, 1994), many individuals appear to have little experience and poor knowledge of advance directives (Sam & Singer, 1993). However, some Canadian patients, family members and health care professionals have been documented to have completed advance directives (Leith, 1998; Perry et al., 1995) and it has been suggested that the incidence of advance directives in Canadian health care will continue to increase (Leith, 1997). While research in critical care identifies that it is important for medical personnel to be aware of whether or not patients have advance directive statements (Goodman et al., 1998), some Canadian hospitals do not have policies regarding advance directives (Rasooly et al, 1994). Research suggests that many nurses require further education about advance directives in order to use them effectively in their daily practice (Crego & Lipp, 1998; Leith, 1998; Woods & DelPapa, 1996). Furthermore, critical care research has identifies that at times, problems may occur with interpreting and honoring advance directives (Ewer & Taubert, 1995). Yet, it has been suggested that advance directives could be beneficial in facilitating discussions about foregoing life-sustaining treatments (Johnson et al., 1995).
CACCN'S Position
CACCN supports an individual's right to direct their own health care including the right to accept or refuse life-sustaining treatment. CACCN believes that advance directives provide an appropriate mechanism by which patients can identify their health care preferences for the event that they become incompetent to make health care decisions. CACCN recognizes that some advance directives can be vague and difficult to implement in clinical practice and recommends that ethical consultation may be appropriate in some instances. CACCN does not believe that all patients should be required to complete an advance directive.
CACCN proposes that critical care nurses should ensure that they have adequate knowledge to provide patients and family members with information about the purpose, advantages, and limitations of advance directives. Critical care nurses need to take the time to reflect and acknowledge their own beliefs regarding advance directives, death and dying, because they may be required to discuss these sensitive issues with patients, family members or significant others. CACCN suggests that critical care nurses should act as patient advocates during discussions about advance directives within the health care team or with patients' family members. Additional roles for critical care nurses with respect to advance directives include providing education and/or conducting research. CACCN encourages critical care nurses to verify that the health care facility where they are currently employed has implemented a policy regarding advance directives.
References
Canadian Home Care Association/Canadian Hospital Association/Canadian Long Term Care Association/Canadian Nurses Association. Canadian Public Health Association/Home Support Canada. (1994). Joint Statement on Advance Directives. Ottawa: Authors.
Canadian Medical Association. (1992). Policy summary on advance directives for resuscitation and other life-saving or sustaining measures, Canadian Medical Association Journal, 146(6), 1072A.
Canadian Nurses Association (1997). The Code of Ethics for Registered Nurses. Ottawa: CNA.
Canadian Nurses Association (1998). Advance directives: The nurses' role. Ethics in Practice, ISSN # 1480-9990. Ottawa.
Crego, P.J. & Lipp, E.J. (1998). Nurses' knowledge of advance directives. American Journal of Critical Care, 7(3), 218-223.
Ewer, M.S. & Taubert, J.K. (1995). Advance directives in the intensive care unit of a tertiary care cancer center. Cancer, 76, 1268-1274.
Goodman, M.D. Tarnoff, M., & Slotman, G.J. (1998). Effect of advance directives on the management of elderly critically ill patients. Critical Care Medicine, 26(4), 701-704.
Hugues, D.L. & Singer, P.A. (1992). Family physicians' attitudes toward advance directives. Canadian Medical Association Journal, 146, 1937-1944.
Johnson, R.F. Baranowski-Birkmeier, T., & O'Donnell, J.B. (1995). Advance directives in the medical intensive care unit of a community teaching hospital. Chest, 107, 752-756.
Kelner, M., Bourgeault, I.L., Hebert, P.C., & Dunn, E.V. (1993). Advance directives: The views of health care professionals. Canadian Medical Association Journal, 148(8), 1331-1338.
Leith, B. (1997). Advance directives in critical care. Official Journal of the Canadian Association of Critical Care Nurses, 8(4), 21-25.
Leith, B. (1998). Canadian critical care nurses and advance directives. Official Journal of the Canadian Association of Critical Care Nurses, 9(1), 6-11.
Molloy, D.W., Guyatt, G., Alemayehu, E., & McIlroy, W.E. (1991). Treatment preferences, attitudes toward advance directives and concerns about health care. Humane Medicine, 7, 285-290.
Perry, L.D., Nicholas, D., Molzahn, A.E., & Dossetor, J.B. (1995). Attitudes of dialysis patients and caregivers regarding advance directives. ANNA Journal, 22, 457-463,481.
Rasooly, I., Lavery, J.V., Urowits, S., Choudhry, S., Seeman, N., Meslin, E.M., Lowy, F.H., & Singer, P.A. (1994). Hospital policies on life-sustaining treatments and advance directives in Canada. Canadian Medical Association Journal, 150(8), 1265-1270.
Sam, M., & Singer, P.A. (1993). Canadian outpatients and advance directives: poor knowledge and little experience but positive attitudes. Canadian Medical Association Journal, 148(9), 1497-1502.
Senate Of Canada. (June 1995). Of Life and Death. Report of the special senate committee on euthanasia and assisted suicide, Minister of Supply and Services Canada.
Silverman, H.J., Vinicky, J.K., & Gasner, M.R. (1992). Advance directives: Implications for critical care. Critical Care Medicine, 20, 1027-1031.
Sneiderman, B. (1991). The Shulman case and the right to refuse treatment. Humane Medicine, 7(1), 15-21.
Storch, J.L. & Dossetor, J. (1994). Public attitudes toward end-of-life treatment decisions: Implications for nurses clinicians and nursing administrator. Canadian Journal of Nursing Administration, 7, 65-89.
Woods, L.C. & DelPapa, L.A. (1996). Nurses' attitudes, ethical reasons, and knowledge of the law concerning advance directives. IMAGE: Journal of Nursing Scholarship, 28(4), 371.