Advance Directives

• Why does informed consent matter?
  • Individuals have the right to live by their values
  • Their values inform medical decision making
  • They need to be informed so they can make choices that best reflect their values
• Gold standard of end of life decision making- informed choice
  • Patients able to make choices based on their values when given proper information
  • Don’t be too quick in assuming patient understands their options
• Silver standard of end of life decision making - advanced directives (living will, Healthcare Power of Attorney/Durable Power of Attorney)
  • Living wills
  • List of do and don’t wants
  • Applicable if a person is unable to make decisions & permanently conscious/terminally ill
  • Problems
    • Narrow scope of applicability
    • Lack an “agent” to assess current circumstances and make choices based on them
  • DPOA/HCPOA- the real silver standard
  • Designates surrogate to make decisions in event that patient cannot → broader scope of applicability
  • may or may not have list of do and don’t wants
  • Problems
    • Designated surrogates need to properly understand, be willing and able to carry out their role
• Bronze standard of end of life decision making- non designated surrogates (unfortunately this tends to be most cases)
  • Problems
  • Identifying proper surrogate
  • Focusing family member/loved one on surrogate’s role
  • Consensus among surrogates
  • Consensus among surrogates and other parties
  • Some states have hierarchy in finding surrogates:
  • Legal guardian
  • Spouse
  • Adult son/daughter or majority 
  • Parent
  • brother/sister or majority
  • Close friend
  • Problem is that these people may not be the closest person/person who understand the patient most
• Fundamental role of surrogate is to help others understand the patient’s values & what the patient would have wanted if they could speak for themselves
• Use best interest standard if surrogate isn’t available and patient can’t make decisions

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