Term Paper on "Advance Directives Family Changing"

Term Paper 10 pages (3485 words) Sources: 5 Style: APA

[EXCERPT] . . . .

Ethics and Advance Directives

Ethics of Changing Advance Directives

Adults have the right and obligation to make decisions concerning their final days in advance. Whether or not to decline life support if death is imminent, or if a coma state becomes permanent is usually an ethical opinion which has already been formed and the adult who makes a directive concerning their own life under those conditions may make this action permanent by creating a living will or a previously prepared power of attorney, or directive which appoints a health care representative which the doctor may ask the patient to prepare in advance and keeps in the patient's file. It is the view of the writer of this paper that a person's advance directive should be followed, no matter how difficult it may be for the family or medical personnel.

As many health facilities would put it, the following are the questions that one must ask oneself as one is deciding on what decisions must be made during end-of-life circumstances:

Who would you like to make treatment decisions for you, if you become unable to so?

How do you feel about ventilators, surgery, resuscitation (CPR), drugs or tube feeding if you were to become terminally ill? If you were unconscious and not likely to wake up? If you were senile?

What kind of medical treatment would you want if you had a severe stroke or other medical condition that made you dependant on others for all your care?

What sort of mental, physical, or social abilities are important for you to enjoy living?

Do you want to receive every treatment your care-givers recommend? (University of Michigan Health Systems, p. 1)

If a patient is put into a circumstance where they cannot and are not able to make the decisions above, that is the time that an advanced directive is utilized, if it is available. The appointment of a person who holds durable power of attorney or health care representative includes the patient's choice of a person they trust who may feel the same as they about end-of-life decisions to be their health care representative, to stand in their stead, as it were, when they are no longer able to direct their own care. It also includes the directive to consult with the doctor, or several doctors, on the best path to choose if there are complex circumstances. In this case, many doctors feel that if a patient stands a chance of recovering and retaining quality of life, then they would direct the health care representative to sustain life support. However, if quality of life would be significantly impaired, doctors who have experience may counsel the health care representative to withdraw life support and allow the patient to die from natural causes. Since relatives often do not share one's same views on end-of-life scenarios, the appointment of a health care representative may extend to close friends or even the minister of one's church.

Living Will also is a legal document which directs whether or not one wishes to be sustained on artificial life support. It may also include appointment of someone one trusts to make wise health care decisions on one's behalf in case one is unable to do so. A Do-Not-Resuscitate (DNR) order may be part of the Living Will as directed in certain circumstances.

In 1991 the U.S. government passed the Patient Self-Determination Act (PSDA) requiring all health-care institutions that receive Medicare of Medicaid to provide patients with information about their state's laws and their rights to execute advanced directives, but it did not require the states to adopt or change existing laws. The information given must state the health institution's policy on withdrawing or withholding life-sustaining treatment. Violation of this law can lead to loss of federal funding for the institution.

It is a legal and binding agreement and contract which the patient has signed and should not be thrown aside for emotion's sake. The reason these documents are necessary is that, should one be sustained in a coma, or even if one is conscious, but at a point where there is a choice of dying or living with terminal illness and pain so much so that quality of life may be compromised. Living with serious handicaps that are so extensive as to make life unbearable impacts every aspect of life for the patient and those around him or her. Emotions may be part of the scenario, as are spiritual questions. Living with excruciating pain, or living on drugs to alleviate pain are both untenable in many people's minds.

To put one's wishes in writing in an advance directive of some sort normally allows the person who made it to decide in advance how health care will be administered. It can spare an anguished family from making decisions which are heart-wrenching and may lead to guilt and recriminations later. However, in cases where families disagree with these directives and wish to change them, ethical questions arise.

When advance directives are legal, that is, they are signed when the person is of sound mind and body, before a notary public and witnesses, then there is little anyone can do to change the directive. However, if the advance directives are made at the point when the patient enters the hospital and are not legal in all aspects, family members may claim that the decisions were made when the person was not of sound mind and body and are therefore not legally binding. In this case, family members may, and sometimes do, change the directives to the medical personnel to keep the patient on life support.

There is merit in the decision to keep a patient on life support when decisions are made while the patient is under the stress of severe illness, perhaps in fever and pain, in that these elements often create a desire to die, whereas when one recovers from an illness, one can make better judgments not based on the present illness. In the throes of a delirium or when experiencing high fever and agonizing pain, all one wishes is to be released from the suffering by any means, even death. However, if one recovers from the illness one may go on to live a full and pain-free life and wonder why one wished to die at that point. In such circumstances where decisions are made that are influenced by emotional and physical states of mind and body from which one may recover, but does not wish to at that particular moment, the decisions of relatives or friends and doctors who can see the circumstances more clearly may be more valid and reasonable than the patient's

However, if the decisions are made on the basis that that one does not know whether the person will live or die and in order to alleviate any guilt they may feel in the future for condemning their relative to death, relatives opt for extreme life sustaining measures, then the reasonableness and validity of this decision may be compromised.

This paper will not address psychiatric advanced directives, since the question of who may decide for a person experiencing mental incompetence or capacity involves many more issues and usually do not involve life-sustaining measures.

When a person is suffering from a disease or condition, such as dementia, and it was clear from their directive that they did not want to live with this condition, and then they develop pneumonia or have an accident that puts them in the hospital, does one treat them, or honor the person's original wishes and allow them to die from the secondary illness or condition? They expressly stated that they do not wish to continue in the state in which they now live and one should allow them to die from the accident or deadly illness. However, this is the very problem which relatives face when they admit an elderly patient with dementia or Alzheimer's disease. They have to decide whether to treat the second condition, as the following study debates:

Dementing illness poses a special problem for the implementation of advance directives. Suppose a now-incompetent person potentially changes her preferences regarding treatment. Suppose further that she is not competent to create a new advance directive, nor can she clearly articulate new preferences or revoke the existing directive. Should her existing directive have authority? Two different accounts offer different responses to this problem. On the first account, existing advance directives do have authority because only competent persons have a right to autonomy and thus a right to plan for their future. Following existing advance directives is a legitimate exercise of precedent autonomy. This first view is predicated on certain assumptions regarding personal identity. Proponents of precedent autonomy, most notably Ronald Dworkin, presume personal identity survives dementing illness. According to the second view, precedent autonomy does not have authority over conscious, incompetent persons because as a result of dementing illness, the now-incompetent self and the prior, competent self are different persons. This second view is also predicated on a… READ MORE

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