Why Are Advance Directives Important

Importance of Advance Directives

When considering the importance of planning for the future, particularly for those in the elderly population, advance directives hold a significant place. They serve as a beacon, guiding medical decisions when individuals may not be able to express their wishes.

Definition and Purpose

Advance directives are documents that allow patients to convey their preferences for medical treatment if they are unable to communicate them. The main purpose of these directives is to ensure that the patient's wishes are known and respected, particularly in situations where critical or end-of-life care decisions need to be made [1].

The question of 'why are advance directives important' can be answered by the role they play in increasing patient autonomy, enhancing communication between patients, families, and healthcare providers, and reducing conflicts or uncertainties that may arise during decision-making processes.

Types of Advance Directives

There are several types of advance directives, each serving a specific purpose yet collectively working towards safeguarding the patient's wishes.

Living Wills: These allow patients to document treatment options they wish to pursue if terminally ill or injured, including specifications regarding life support measures, CPR, ventilation, dialysis, and artificial hydration and nutrition.
Health Care Proxies: These are individuals designated by the patient to make health care decisions on their behalf if they become incapacitated. Physicians may need to rely on those who do not legally represent the patient as proxy, but who are familiar with the patient's wishes.
Do Not Resuscitate (DNR) Orders: These orders vary by state and may not be recognized in the out-of-hospital setting. Emergency medical system (EMS) personnel may be required to initiate resuscitative measures unless state-approved documentation can be provided.
Physician Orders for Life-Sustaining Treatment (POLST): These are portable medical orders designed to assist health care providers in implementing a patient's medical wishes. POLST orders contain instructions for CPR, medical interventions, antibiotics, artificially administered nutrition, and reasoning for the orders.

By understanding the different types of advance directives, individuals can make informed decisions about which form(s) best aligns with their personal values and medical preferences. This, in turn, ensures that their wishes are respected and followed, even in their inability to communicate them directly.

Components of Advance Directives

Advance directives are composed of critical documents such as living wills and health care proxies. These components play vital roles in addressing what medical decisions should be made if a person becomes unable to communicate or make decisions for themselves. They are central to the question of why advance directives are important.

Living Wills

A living will, one component of an advance directive, is a written document specifying what medical treatments a patient would want or not want under certain medical conditions, such as terminal illness or a vegetative state. This will directs health care providers on what actions to take or not to take in such situations [2].

Living wills allow patients to document treatment options they wish to pursue if they become terminally ill or seriously injured. These options may include specifications regarding life support measures, cardiopulmonary resuscitation (CPR), ventilation, dialysis, and artificial hydration and nutrition.

Health Care Proxies

Health care proxies, also known as health care agents, are individuals designated by the patient to make health care decisions on their behalf if they become incapacitated. It is essential to choose a health care proxy through a medical or health care power of attorney. This selection provides patients with someone who can make decisions on their behalf when they are unable to do so, ensuring that appropriate medical care preferences are followed.

Physicians may need to rely on individuals who do not legally represent the patient as a proxy, but who are familiar with the patient's wishes. This highlights the importance of having clear and open conversations with loved ones about one's preferences for medical care [1].

In summary, the living will and health care proxy are the two primary components of an advance directive, each serving to safeguard the medical wishes of an individual should they become unable to communicate or make decisions on their own. This underscores the significance of advance directives in ensuring patient autonomy and upholding the consistency of medical decisions.

Specific Orders

In addition to general advance directives, there are also specific orders that can be put in place to guide medical decisions in case of an emergency. These include Do Not Resuscitate (DNR) orders and Physician Orders for Life-Sustaining Treatment (POLST).

Do Not Resuscitate (DNR) Orders

A Do Not Resuscitate order, or DNR, is a specific type of advance directive that dictates whether or not medical personnel should perform CPR or other life-saving measures if a patient stops breathing or their heart stops beating.

It's important to note that DNR orders can vary by state and may not always be recognized outside of a hospital setting. For instance, Emergency Medical Services (EMS) personnel may be mandated to initiate resuscitative measures unless they're provided with state-approved documentation.

A DNR order can be part of a larger advance directive document, or it may stand on its own. It should be discussed and established with a healthcare provider and clearly communicated to family members and caregivers.

Physician Orders for Life-Sustaining Treatment (POLST)

Physician Orders for Life-Sustaining Treatment, or POLST, is another type of specific directive that provides more detailed instructions than a DNR. Also known as Medical Orders for Life-Sustaining Treatment (MOLST), these documents are portable medical orders designed to assist healthcare providers in implementing a patient's medical wishes.

A POLST order can contain instructions for a variety of interventions, including CPR, medical therapies, antibiotics, and artificially administered nutrition. It can also provide reasoning for the orders, offering further context for healthcare providers [1].

POLST orders are typically recommended for patients who are seriously ill or frail, and whose health care professionals wouldn't be surprised if they died within a year. They aim to ensure that a patient's wishes are followed by all healthcare professionals, across settings of care.

Both DNR and POLST orders play crucial roles in ensuring an individual’s wishes are respected when they aren't able to communicate them personally, highlighting why advance directives are important. They provide clear instructions for healthcare providers and can help to prevent unnecessary or unwanted medical interventions.

Legal Aspects

Understanding the legal aspects of advance directives is crucial in appreciating why advance directives are important. This comprehension includes knowledge on the competency and validity of the individual issuing the directive and the legal enforcement of the directive.

Competency and Validity

Advance directives must be made while an individual is still competent; they cannot be done by anyone else. Competency refers to the ability to make important decisions for oneself. The directive only comes into effect if the individual loses competency.

Every province and territory in Canada has laws that outline the requirements for a valid advance directive, ensuring that individuals have the opportunity to express their end-of-life wishes and values. These laws are critical in validating the individual's wishes and ensuring that a directive is made without coercion or manipulation.

Legal Enforcement

Canadian courts have ruled that healthcare providers, including doctors, must respect valid advance directives. In a notable case, Malette v Shulman, the Ontario Court of Appeal emphasized that a doctor cannot disregard a patient's advance instructions or emergency instructions [4].

This ruling demonstrates the legal obligation of health professionals to adhere to a patient's advance directive, underscoring the legal protection for patients' autonomy. Each province and territory in Canada has laws governing valid advance directives, highlighting the importance of understanding and adhering to these laws when creating advance directives [4].

In summary, the legal aspects of advance directives serve to protect the rights of patients to make medical decisions for their future selves, ensuring their wishes are respected and followed even when they may not be able to express them directly.

Benefits of Advance Directives

Understanding the benefits of advance directives is crucial as it can help individuals be better prepared for the future, particularly when it comes to medical and end-of-life decisions. Let's delve into the key benefits of these documents, focusing on patient autonomy and the consistency of medical decisions.

Patient Autonomy

One of the primary benefits of advance directives is the preservation of patient autonomy. They empower patients to express their desires and maintain control over their treatment plan if they become incapacitated near the end of life. These directives are based on the principle of precedent autonomy, where the patient's directives documented during a prior period of capacity are followed.

Advance directives are crucial in ensuring that an individual's wishes and values are honored in important decisions, particularly healthcare decisions when the individual is unable to make these decisions for themselves [4]. By taking the time to draft these directives, individuals can ensure that their wishes regarding medical treatment are respected, no matter the circumstances.

Medical Decision Consistency

Another significant benefit of advance directives is the consistency they bring to medical decision-making. By clearly stating a patient's preferences, they guide healthcare providers in providing care that aligns with the patient's wishes.

Advance directives can reduce the number and subsequent expenses associated with medical interventions during the final months of a patient's life, as well as prevent unnecessary suffering and emotional strain for patients and their families [5].

Documents like advance directives can help ensure that your loved ones and your healthcare team honor your wishes, offering peace of mind and eliminating confusion in difficult times.

In summary, advance directives are an essential tool for safeguarding an individual's autonomy and ensuring consistency in medical decisions, especially when the individual is unable to communicate their wishes. They serve as a roadmap for healthcare providers and loved ones, providing clear instructions on how to proceed with medical treatment. This is why advance directives are important - they offer individuals the ability to dictate their medical care, ensuring their wishes are respected and upheld.

Ethical Considerations

While discussing why advance directives are important, it's crucial to understand the ethical implications that come into play. These legal documents primarily fall within the realm of medical ethics, specifically the concept of autonomy or self-determination.

Autonomy vs. Beneficence

The principle of autonomy, as applied to advance directives, allows patients to express their desires and maintain control over their treatment plan if they become incapacitated near the end of life [5]. This principle respects the patient's independence and their right to make decisions about their own healthcare.

On the other hand, the principle of beneficence refers to the ethical obligation of healthcare providers to do good and prevent harm to the patient. In the context of advance directives, this principle ensures that the healthcare provider acts in the best interest of the patient, even if the patient is unable to communicate their wishes.

It's important to strike a balance between these two principles. While the patient's autonomy should be respected, healthcare providers also have a responsibility to ensure that the patient receives the best care possible. To this end, advance directives play an instrumental role in communicating the patient's wishes to the healthcare team.

Substituted Judgment Approach

Advance directives also serve as a valuable record to assist healthcare surrogates and providers in delivering care that aligns with patients' wishes, particularly in nuanced or evolving situations. This concept is commonly known as substituted judgment.

The substituted judgment approach allows a surrogate decision-maker to make healthcare decisions on behalf of the patient, based on what the patient would have wanted. This approach is particularly useful when the patient's preferences are not clearly outlined in the advance directive.

The ethical considerations surrounding advance directives are complex and multifaceted. However, these documents are essential in ensuring that an individual's wishes and values are honored in important decisions, particularly healthcare decisions, when the individual is unable to make these decisions for themselves.