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