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