The Dangers of Directives or the False Security of Forms

Journal of Law, Medicine and Ethics

Volumn 24, Issue 1, 1996, Pages 5-17

  Hoffmann, Diane E ^a   Zimmerman, Sheryl Itkin ^a   Tompkins, Catherine J ^a  

^a NONE

Author keywords

[No Author keywords available]

Indexed keywords

AGED; ARTICLE; COMPREHENSION; DOCUMENTATION; EMPIRICAL APPROACH; FEMALE; HUMAN; INFORMATION PROCESSING; LEGAL ASPECT; LIVING WILL; MALE; PROFESSIONAL PATIENT RELATIONSHIP; QUESTIONNAIRE; TERMINAL CARE; UNITED STATES;

EMPIRICAL APPROACH; PROFESSIONAL PATIENT RELATIONSHIP;

ADVANCE DIRECTIVES; AGED; COMPREHENSION; DOCUMENTATION; FEMALE; HUMANS; MALE; MARYLAND; QUESTIONNAIRES; RECORDS; TERMINAL CARE; UNITED STATES;

EID: 0030092768     PISSN: 10731105     EISSN: None     Source Type: Journal    
DOI: 10.1111/j.1748-720X.1996.tb01829.x     Document Type: Article

References (61)

1. G.A. Sachs, C.B. Stocking, and S.H. Miles, "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; M. Devor et al., "Compliance with Social and Safety Recommendations in an Outpatient Comprehensive Geriatric Assessment Program," Journal of Gerontology, 49 (1994): M168-M173; and L.L. Emanuel and E.J. Emanuel, "Decisions at the End of Life: Guided by Communities of Patients," Hastings Center Report, 23, no. 5 (1993): 6-14.
2. G.A. Sachs, C.B. Stocking, and S.H. Miles, "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; M. Devor et al., "Compliance with Social and Safety Recommendations in an Outpatient Comprehensive Geriatric Assessment Program," Journal of Gerontology, 49 (1994): M168-M173; and L.L. Emanuel and E.J. Emanuel, "Decisions at the End of Life: Guided by Communities of Patients," Hastings Center Report, 23, no. 5 (1993): 6-14.
3. G.A. Sachs, C.B. Stocking, and S.H. Miles, "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; M. Devor et al., "Compliance with Social and Safety Recommendations in an Outpatient Comprehensive Geriatric Assessment Program," Journal of Gerontology, 49 (1994): M168-M173; and L.L. Emanuel and E.J. Emanuel, "Decisions at the End of Life: Guided by Communities of Patients," Hastings Center Report, 23, no. 5 (1993): 6-14.
4. N. Lurie et al., "Attitudes Toward Discussing Life Sustaining Treatments in Extended Care Facility Patients," Journal of the American Geriatric Society, 40 (1992): 1205-08; and G. Sachs, "Increasing the Prevalence of Advance Care Planning," Hastings Center Report, 24, no. 6 (1994): S13-S16.
5. N. Lurie et al., "Attitudes Toward Discussing Life Sustaining Treatments in Extended Care Facility Patients," Journal of the American Geriatric Society, 40 (1992): 1205-08; and G. Sachs, "Increasing the Prevalence of Advance Care Planning," Hastings Center Report, 24, no. 6 (1994): S13-S16.
6. M.K. Robinson, M.J. DeHaven, and K.A. Koch, "Effects of the Patient Self-Determination Act on Patient Knowledge and Behavior," Journal of Family Practice, 37 (1993): 363-68.
7. Id.
8. Robinson, DeHaven, and 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).
9. Robinson, DeHaven, and 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).
10. Id.
11. D. High, "Who Will Make Health Care Decisions for Me When I Can't?," Journal on Aging and Health, 2 (1990): 291-309; and J. Cohen-Mansfield 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.
12. D. High, "Who Will Make Health Care Decisions for Me When I Can't?," Journal on Aging and Health, 2 (1990): 291-309; and J. Cohen-Mansfield 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.
13. Cohen-Mansfield et al., supra note 7; J. Hare and C.C. Nelson, "Will Outpatients Complete Living Wills? A Comparison of Two Interventions," Journal of General Internal Medicine, 6 (1991): 41-46; D.M. High, "Advance Directives and the Elderly: A Study of Intervention Strategies to Increase Use," Gerontologist, 33 (1993): 342-49; and M.K. Luptak and C. Boult, "A Method for Increasing Elders' Use of Advance Directives," Gerontologist, 34 (1994): 409-12.
14. Cohen-Mansfield et al., supra note 7; J. Hare and C.C. Nelson, "Will Outpatients Complete Living Wills? A Comparison of Two Interventions," Journal of General Internal Medicine, 6 (1991): 41-46; D.M. High, "Advance Directives and the Elderly: A Study of Intervention Strategies to Increase Use," Gerontologist, 33 (1993): 342-49; and M.K. Luptak and C. Boult, "A Method for Increasing Elders' Use of Advance Directives," Gerontologist, 34 (1994): 409-12.
15. Cohen-Mansfield et al., supra note 7; J. Hare and C.C. Nelson, "Will Outpatients Complete Living Wills? A Comparison of Two Interventions," Journal of General Internal Medicine, 6 (1991): 41-46; D.M. High, "Advance Directives and the Elderly: A Study of Intervention Strategies to Increase Use," Gerontologist, 33 (1993): 342-49; and M.K. Luptak and C. Boult, "A Method for Increasing Elders' Use of Advance Directives," Gerontologist, 34 (1994): 409-12.
16. Cohen-Mansfield et al., supra note 7; J. Hare and C.C. Nelson, "Will Outpatients Complete Living Wills? A Comparison of Two Interventions," Journal of General Internal Medicine, 6 (1991): 41-46; D.M. High, "Advance Directives and the Elderly: A Study of Intervention Strategies to Increase Use," Gerontologist, 33 (1993): 342-49; and M.K. Luptak and C. Boult, "A Method for Increasing Elders' Use of Advance Directives," Gerontologist, 34 (1994): 409-12.
17. 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; M. Danis et al., "A Prospective Study of Advance Directives for Life Sustaining Care," N. Engl. J. Med., 324 (1991): 882-88; M. Danis, "Following Advance Directives," Hastings Center Report, 24, no. 6 (1994): S21-S23; and R.S. Morrison et al., "The Inaccessibility of Advance Directives on Transfer from Ambulatory to Acute Care Settings," JAMA, 274 (1995): 478-82.
18. 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; M. Danis et al., "A Prospective Study of Advance Directives for Life Sustaining Care," N. Engl. J. Med., 324 (1991): 882-88; M. Danis, "Following Advance Directives," Hastings Center Report, 24, no. 6 (1994): S21-S23; and R.S. Morrison et al., "The Inaccessibility of Advance Directives on Transfer from Ambulatory to Acute Care Settings," JAMA, 274 (1995): 478-82.
19. 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; M. Danis et al., "A Prospective Study of Advance Directives for Life Sustaining Care," N. Engl. J. Med., 324 (1991): 882-88; M. Danis, "Following Advance Directives," Hastings Center Report, 24, no. 6 (1994): S21-S23; and R.S. Morrison et al., "The Inaccessibility of Advance Directives on Transfer from Ambulatory to Acute Care Settings," JAMA, 274 (1995): 478-82.
20. 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; M. Danis et al., "A Prospective Study of Advance Directives for Life Sustaining Care," N. Engl. J. Med., 324 (1991): 882-88; M. Danis, "Following Advance Directives," Hastings Center Report, 24, no. 6 (1994): S21-S23; and R.S. Morrison et al., "The Inaccessibility of Advance Directives on Transfer from Ambulatory to Acute Care Settings," JAMA, 274 (1995): 478-82.
21. Sachs, supra note 2;
22. and S. Evans and P. Clarke, "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): 20-27.
23. Patient Self-Determination Act 42 U.S.C. §§ 1395cc, 1396a (1994).
24. The exceptions are Delaware, New Jersey, and Ohio.
25. 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 Term. Code Ann. §§ 34-6-203, -205 (1991 & Supp. 1995).
26. 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).
27. D.E. Hoffmann, "The Maryland Health Care Decisions Act: Achieving the Right Balance," Maryland Law Review, 53 (1994): 1064-130.
28. L.L. Emanuel and E.J. Emanuel, "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.
29. A.S. Brett, "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.
30. W.R. Mower and L.J. Baraff, "Effect of Type of Directive on Physicians' Therapeutic Decisions," Archives of Internal Medicine, 153 (1993): 375-81.
31. 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).
32. 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.
33. 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)).
34. 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).
35. N.D. Cent. Code § 23-06.4-03 (Supp. 1995).
36. See, for example, Nev. Rev. Stat. §§ 449.610, -.613, -.830 (Supp. 1995).
37. 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).
38. 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.").
39. 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).
40. 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).
41. Md. Code Ann., Health-Gen. § 5-603 (Supp. 1995).
42. Or. Rev. Stat. § 127.531 (Supp. 1994).
43. 20 Pa. Cons. Stat. § 5404 (Supp. 1995).
44. 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
45. 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).
46. 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).
47. S.C. Code Ann. § 62-5-504 (Law. Co-op. Supp. 1995).
48. 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).
49. Uniform Health Care Decisions Act § 1-19, 9 U.L.A. 201 (Supp. 1995).
50. Me. Rev. Stat. Ann. tit. 18-A, § 5-804 (West Supp. 1995); and N.M. Stat. Ann. § 24-7A-4 (Michie Supp. 1995).
51. Md. Code Ann., Health-Gen. § 5-601 to -608 (1993 & Supp. 1995).
52. The form includes space for individuals to write in other instructions as well as how they want their decisions regarding life-sustaining treatment modified if they are pregnant. In 1994, an inadvertent error was incorporated into the Annual Corrective Bill approved by the Maryland legislature. The bill deleted the provisions of the advance directive form that allow individuals to state a preference regarding pain medication or to state that they want all available medical treatment no matter what their condition. Despite this omission, the form continued to be distributed by the Attorney General's Office and the Office of Legislative Reference as originally passed. In the 1996 legislative session, a corrective bill was passed, returning the form to its pre-1994 status.
53. Uniform Health Care Decisions Act § 4, 9 U.L.A. 207 (Supp. 1995).
54. Veterans Administration Form 10-0137C (Nov. 1991).
55. 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).
56. T.C. David et al., "The Gap Between Patient Reading Comprehension and the Readability of Patient Education Materials," Journal of Family Practice, 31 (1990): 533-38.
57. L.L. Emanuel et al., "Advance Directives: Stability of Patients' Treatment Choices," Archives of Internal Medicine, 154 (1994): 209-18.
58. A. Sehgal et al., "How Strictly Do Dialysis Patients Want Their Advance Directives Followed?," JAMA, 267 (1992): 59-63.
59. T. Wetle, "Individual Preferences and Advance Directives," Hastings Center Report, 24 (1994): S55-S58.
60. L. Forrow, "The Green Eggs and Ham Phenomena," Hastings Center Report, 24 (1994): S29-S32.
61. E.J. Emanuel, L.L. Emanuel, and D. Orentlicher, letter, "Advance Directives," JAMA, 266 (1991): 2563.