Advance Care Planning by Proxy for Residents of Long-Term Care Facilities Who Lack Decision-Making Capacity
Ladislav Volicer MD, PhD
Geriatric Research, Education and Clinical Center, Dementia Study Unit, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts;
Search for more papers by this authorMichael D. Cantor MD, JD
The National Center for Ethics of the Veterans Health Administration, Washington, DC;
Search for more papers by this authorArthur R. Derse MD, JD
Center for the Study of Bioethics and the Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin;
Search for more papers by this authorDenise Murray Edwards RNCS, ARNP, MA, MEd, MTS
The Center for Health and Well-Being, West Des Moines, Iowa;
Search for more papers by this authorAngela M. Prudhomme JD
Office of the General Counsel of the Department of Veterans Affairs, Washington, DC;
Search for more papers by this authorJames E. Reagan PhD
The National Center for Ethics of the Veterans Health Administration, Washington, DC;
Search for more papers by this authorJames A. Tulsky MD
The Center for Health Services Research in Primary Care, Durham Veterans Administration Medical Center, Durham, North Carolina.
Search for more papers by this authorEllen Fox MD
The National Center for Ethics of the Veterans Health Administration, Washington, DC;
Search for more papers by this authorThe National Ethics Committee of the Veterans Health Administration
Search for more papers by this authorLadislav Volicer MD, PhD
Geriatric Research, Education and Clinical Center, Dementia Study Unit, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts;
Search for more papers by this authorMichael D. Cantor MD, JD
The National Center for Ethics of the Veterans Health Administration, Washington, DC;
Search for more papers by this authorArthur R. Derse MD, JD
Center for the Study of Bioethics and the Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin;
Search for more papers by this authorDenise Murray Edwards RNCS, ARNP, MA, MEd, MTS
The Center for Health and Well-Being, West Des Moines, Iowa;
Search for more papers by this authorAngela M. Prudhomme JD
Office of the General Counsel of the Department of Veterans Affairs, Washington, DC;
Search for more papers by this authorJames E. Reagan PhD
The National Center for Ethics of the Veterans Health Administration, Washington, DC;
Search for more papers by this authorJames A. Tulsky MD
The Center for Health Services Research in Primary Care, Durham Veterans Administration Medical Center, Durham, North Carolina.
Search for more papers by this authorEllen Fox MD
The National Center for Ethics of the Veterans Health Administration, Washington, DC;
Search for more papers by this authorThe National Ethics Committee of the Veterans Health Administration
Search for more papers by this authorThe views expressed in this article do not necessarily represent the views of the Department of Veterans Affairs or of the United States Government.
Abstract
This report examines whether long-term care facilities should implement policies and procedures to support advance care planning by proxy for residents who lack decision-making capacity. The report focuses on advance care planning in the Department of Veterans Affairs. After reviewing clinical, legal, and ethical perspectives, the authors conclude that advance proxy planning is ethically sound and can improve patient care. However, because experience with advance proxy planning is still fairly limited, the authors do not recommend that a particular standardized approach be mandated at the national level. Instead, local facilities are advised to develop their own policies and then evaluate their effect. The report contains specific recommendations for the advance proxy planning process.
REFERENCES
- 1 Lynn J, Teno J. Advance directives. In: WT Reich, ed. Encyclopedia of Bioethics. New York, NY: Simon & Schuster Macmillan, 1995, pp 572–577.
- 2 Emanuel LL, Barry MJ, Stoeckle JD et al. Advance directives for medical care: A case for greater use. N Engl J Med 1991; 324: 889–895.
- 3 Hamm G, States J, Belak T. Current issues in medicolegal practice: The next step in advance directives. Fed Pract 1995; 12: 54–55.
- 4 Robinson EM, Hurley AC, Volicer L. Advance proxy planning in patients who become incompetent. Fed Pract 1998; 15: 26–42.
- 5 La Puma J, Orentlicher D, Moss RJ. Advance directives on admission: Clinical implications and analysis of the Patient Self-Determination Act of 1990. JAMA 1991; 266: 402–405.
- 6 Teno JM, Branco KJ, Mor V et al. Changes in advance care planning in nursing homes before and after the Patient Self-Determination Act: Report of a 10-state survey. J Am Geriatr Soc 1997; 45: 939–944.
- 7 Bradley CH, Wetle T, Horwitz SM. The Patient Self-Determination Act and advance directive completion in nursing homes. Arch Fam Med 1998; 7: 417–423.
- 8 Lo B, McLeod G, Saika G. Patient attitudes towards discussing life-sustaining treatment. Arch Intern Med 1986; 146: 1613–1615.
- 9 Edinger W, Smucker DR. Outpatient's attitudes regarding advance directives. J Fam Pract 1992; 35: 650–653.
- 10 Heffner JE, Fahy B, Hilling L et al. Attitudes regarding advance directives among patients in rehabilitation. Am J Respir Crit Care Med 1996; 154(6 Pt 1): 1735–1740.
- 11 In re Quinlan, 355 A.2d 647 (N.J. 1976).
- 12 Buchanan AE, Brock, DW. Deciding for Others: The Ethics of Surrogate Decision Making. New York, NY: Cambridge University Press, 1989.
- 13 Veterans Health Administration. Informed consent. VHA Handbook Section 1004.1, August 1, 1996.
- 14 Veterans Health Administration. Advance care planning. VHA Handbook Section 1004.2, July 6, 1998.
- 15 Veterans Health Administration. Do not resuscitate (DNR) protocols within the Department of Veterans Affairs (VA). VA Policy Manual, M-2, Part I, Chapter 30, Section 30.03b(2)(b), June 21, 1994.
- 16 Rowles GD, High DM. Individualizing care: Family roles in nursing home decision-making. J Gerontol Nurs 1996; 22: 20–25.
- 17 Molloy DW, Guyatt GH, Russo R et al. Systematic implementation of an advance directive program in nursing homes: A randomized controlled trial. JAMA 2000; 283: 1437–1444.
- 18 Emanuel EJ, Emanuel LL. Proxy decision making for incompetent patients: An ethical and empirical analysis. JAMA 1992; 267: 2067–2071.
- 19 Brock DW. What is the moral authority of family members to act as surrogates for incompetent patients? Milbank Q 1996; 74: 599–618.
- 20 Beauchamp T, Childress G. Principles of Biomedical Ethics, 4th Ed. New York, NY: Oxford University Press, 1994.
- 21 High DM. Foregoing life-sustaining procedures: Survey and analysis of Kentuckians' opinions. J Ky Med Assoc 1988; 86: 293–295.
- 22 Sehgal A, Galbraith A, Chesney M et al. How strictly do dialysis patients want their advance directives followed? JAMA 1992; 267: 59–63.
- 23 Puchalski CM, Zhong Z, Jacobs MM et al. Patients who want their family and physician to make resuscitation decisions for them; observations from SUPPORT and HELP. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. Hospitalized Elderly Longitudinal Project. J Am Geriatr Soc 2000; 48: S84–S90.
- 24 Partnership for Caring. State Statutes Governing Surrogate Decision-making. In: End of Life Digest. New York, NY: Partnership for Caring, 2000.
- 25 American Bar Association Commission on Legal Problems of the Elderly. Health care power of attorney and combined advance directive legislation. 2000. Available: http://www.abanet.org/ftp/pub/elderly/HCPA-CHT00.pdf. Accessed July 10, 2001.
- 26 Ark. Code Ann. §20–17–214 (Michie 2000).
- 27 La. Rev Stat. Ann. §40:1299.58.5 (West 2000).
- 28 La. Rev Stat. Ann. §40:1299.58.6 (West 2000).
- 29 Tex. Health & Safety Code Ann. §166.035 (West 2000).
- 30 N.M. Stat. Ann. §24–7A-6.1 (Michie 2000).
- 31 Tolle SW, Tilden VP, Nelson CA et al. A prospective study of the efficacy of the physician order form for life-sustaining treatment. J Am Geriatr Soc 1998; 46: 1097–1102.
- 32 Hurley AC, Bottino R, Volicer L. Nursing role in advance proxy planning for Alzheimer patients. Caring 1994; 13: 72–76.
