Advance directives. Stability of patients' treatment choices

Emanuel, Linda L.; Emanuel, Ezekiel J.; Stoeckle, John D.; Hummel, Lacinda R.; Barry, Michael J.

doi:10.1001/archinte.154.2.209

Cited by 107 publications

(87 citation statements)

References 32 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…However, a follow-up study of the same cohort of outpatients demonstrated reasonable stability. 29 Another possibility is that family members or the physician may have been unaware of, or overrode the patient's preferences. 7,14,15 Some patients may wish to allow their physicians latitude when acting on their preferences, as other commentators have suggested.…”

Section: Discussionmentioning

confidence: 99%

Comparing utilization of life-sustaining treatments with patient and public preferences

Alpert

Emanuel

1998

J Gen Intern Med

View full text Add to dashboard Cite

OBJECTIVE:The movement for advance planning of endof-life care was motivated in part by the assumption that medical intervention for terminally ill patients varies from what these patients would prefer. We examined the validity of this assumption by comparing actual life-sustaining treatment practices for patients in critical illness scenarios and surveyed patients' advance care preferences. MEASUREMENTS AND MAIN RESULTS:We selected at random and reviewed 7,400 inpatient medical records from a single urban teaching hospital during the period just prior to the Patient Self-Determination Act. Records of 198 patients with conditions that matched advance directive scenarios were examined, and practices to withhold or withdraw seven life-sustaining treatments were documented. Practices were compared with surveyed preferences of 102 members of the general public and 495 outpatients who were followed by the same physicians as the 198 patients. Concordance of practices and preferences for the 19 surveyed outpatients who eventually fell into one of the scenarios was also evaluated. One hundred sixty-seven inpatient cases met review criteria for the scenario coma with a small chance of recovery . Hospital patients received medical interventions that were not consistently greater or less than the preferences of the surveyed outpatients or members of the general public. Resuscitation, the most frequently withheld treatment (94% of cases), was withheld more often than surveyed preferences to decline it (56% of outpatients, p Ͻ .001). Four treatments-mechanical breathing, artificial nutrition, major surgery, and hemodialysis-were utilized comparably to surveyed outpatients' preferences (range p ‫؍‬ .704-.055). Antibiotics and artificial hydration were withheld (9% and 6%, respectively) less often than surveyed outpatient's prior preferences to decline them (48% and 52%, respectively, p Ͻ .001 for each). Conversely, treatments given to the 19 surveyed patients who subsequently developed one of the illness scenarios were often incongruent with the patients' prior preferences. Again, in some cases more interventions were provided (26 of 63 declined treatments were given), and in some cases less (10 of 21 desired treatments were withheld). CONCLUSIONS:This study does not support the assumption that, collectively, patients' advance care preferences are less interventionist than actual practices for patients in corresponding scenarios. Nevertheless, these results do support the assumption that life-sustaining treatment decisions do not conform well to individual patients' specific preferences. Progress in end-of-life care should focus on shared decision making at the patient-proxy-physician level rather than on overall life-sustaining treatments utilization. L ife-sustaining treatment decisions made for unconscious patients in the absence of advance directives are often assumed, first, to be discordant with individuals' prior preferences, 1 and second, to result in more treatments at the end of life than patients would have wanted....

show abstract

Section: Discussionmentioning

confidence: 99%

Comparing utilization of life-sustaining treatments with patient and public preferences

Alpert

Emanuel

1998

J Gen Intern Med

View full text Add to dashboard Cite

show abstract

“…The first is a series of studies that show how individuals' own preferences regarding lifesustaining treatment change over time. [10][11][12][13] In such studies, people are given health scenarios and asked whether they would want certain medical interventions. They are then resurveyed at later times.…”

Section: The Evidence Against Substituted Judgmentmentioning

confidence: 99%

“…These studies show that many individuals change their own wishes with regard to lifesustaining treatment over time. [10][11][12] In one study over half of patients who initially said yes to a series of medical procedures changed their minds over two years. 13 Furthermore, mindchanging is not random.…”

Section: The Evidence Against Substituted Judgmentmentioning

confidence: 99%

Substituted Judgment: The Limitations of Autonomy in Surrogate Decision Making

2008

View full text Add to dashboard Cite

“…These values include preferences for autonomous versus shared decision making (Blackhall et al, 1995), concern for individual versus family or community interests (Klessig, 1992), beliefs in sanctity of life or possibility of miracles (Klessig, 1992), and personal ideas about what makes life worth living versus intolerable (Ditto, Druley, Moore, Danks, & Smucker, 1996). Although there is evidence that values-related variables do correspond to decision outcomes (Fischer, Alpert, Stoeckle, & Emanuel, 1997;Schonwetter, Walker, Solomon, Indurkhya, & Robinson, 1996), there is mixed evidence regarding the stability of and relationship between values and treatment preferences through time (Ditto et al, 2003;Emanuel, Emanuel, Stoeckle, Hummel, & Barry, 1994;Lockhart, Ditto, Danks, Coppola, & Smucker, 2001). …”

Section: Va Author Manuscriptmentioning

confidence: 99%

Three Methods of Assessing Values for Advance Care Planning

Karel¹,

et al. 2007

View full text Add to dashboard Cite

Advance care planning ideally includes communication about values between patients, family members, and care providers. This study examined the utility of health care values assessment tools for older adults with and without dementia. Adults aged 60 and older, with and without dementia, completed three values assessment tools-open-ended, forced-choice, and rating scale questions-and named a preferred surrogate decision maker. Responses to forced-choice items were examined at 9-month retest. Adults with and without dementia appeared equally able to respond meaningfully to questions about values regarding quality of life and health care decisions. People with dementia were generally as able as controls to respond consistently after 9 months. Although values assessment methods show promise, further item and scale development work is needed. Older adults with dementia should be included in clarifying values for advance care planning to the extent that they desire and are able. Keywords advance care planning; values; dementiaOlder adults at risk for dementia or with early dementia may be particularly interested to engage in advance care planning. Broadly speaking, advance care planning entails communicating with loved ones, health care providers, or other relevant parties to prepare for decisions that may need to be made during a time of future decisional incapacity. For older adults at risk for dementia, such planning might entail preparing for financial, residential, and/or health care eventualities. Within the health care realm, advance care planning has primarily focused on the completion of advance directives that allow individuals to designate surrogate decision makers (i.e., durable power of attorney for health care) or to document particular health care instructions (i.e., living will). However, research and clinical evidence suggests that completing advance directives-in the absence of communication about an individual's and his or her family's values, fears, and preferences -may not ultimately help to facilitate good decisions on behalf of individuals with dementia or other incapacitating illnesses (Covinsky et al., 2000;Miles, Koepp, & Weber, 1996;Teno et al., 1997).Please address correspondence to Michele J. Karel, PhD, Psychology Service 3-5-C, Brockton VA Medical Center, 940 Belmont Street, Brockton, MA 02301; Michele.Karel@va.gov.. Authors' Note: Adam Bank is now in independent practice in Weston, Florida. Armin Azar is now at the Department of Psychological and Brain Sciences, University of Louisville, Kentucky. U.S. Department of Veterans AffairsPublic Access Author manuscript J Aging Health. Author manuscript; available in PMC 2016 May 06. VA Author Manuscript VA Author Manuscript VA Author ManuscriptA process of values clarification in advance care planning recognizes both that individuals differ in health-care related beliefs and preferences and that medical decisions are made within a social context. With regard to individual differences, cultural (Blackhall, Murphy, Frank, Michel, & Aze...

show abstract

Advance directives. Stability of patients' treatment choices

Cited by 107 publications

References 32 publications

Comparing utilization of life-sustaining treatments with patient and public preferences

Comparing utilization of life-sustaining treatments with patient and public preferences

Substituted Judgment: The Limitations of Autonomy in Surrogate Decision Making

Three Methods of Assessing Values for Advance Care Planning

Contact Info

Product

Resources

About