Advanced directives are legal documents that specify a person's medical wishes in case they become unable to make decisions themselves. There are several types, including living wills, durable power of attorney, and health care proxies. A living will outlines preferences for life-sustaining treatments. A durable power of attorney designates someone to make medical and financial decisions. Health care proxies appoint a surrogate decision maker. The Patient Self-Determination Act protects patient rights regarding advance directives and medical decision making. However, ethical issues can arise regarding competency determinations and disagreements between patients, families and medical staff over treatment plans.

1. Advanced Directives:
When our wishes are not always what happens.
Danielle M Smith
HA 575 Legal and Ethical Perspectives
Saint Joseph’s College of Maine

2. What is a advanced directive ?
• Advance directives are legal documents that
state the patient’s wishes when the patient
becomes unable to speak for themselves.
• Advanced directives are created ahead of any
medical incapacitation in order to ensure that
the patient has the ability to make their own
decisions when they are unable to do so.
(Morrison, 2010)

3. Types of Advanced Directives
• Living Will
• Durable Power of Attorney
• Surrogate Decision Maker
▫ Substitute Judgment
• Guardianship
• Health Care Proxy
(Morrison, 2010)

4. Living Will
• A living will is a legal document that discloses a persons
individual needs and requests when unable to make
competent decisions on their own.
• Living will should be validated by two witnesses that are not
related to the patient. (Morrison ,2010)
• Decisions that a living will can address are:
▫ Life-support treatments such as mechanical ventilation ,
cardiopulmonary resuscitation (CPR) and life sustaining
medications.
▫ Nutrition and hydration—feeding tubes & artificial nutrition
▫ Guardianship or decision maker appointment
▫ Dialysis and organ donation (Advanced directives, 2014)

5. Durable Power of Attorney
• “A durable power of attorney is a legal device that
permits one individual, known as a “principle”, to give to
another person called the “attorney-in-fact”, the
authority to act on his or her behalf” (Morrison, 2010)
• The attorney-in-fact that is appointed is giving the
responsibility to take care of banking, legal and real
estate decision making for a specified amount of time
that may be for a lifetime if needed. (Morrison, 2010)
• Issues with a durable power of attorney is the appointed
“attorney-in-fact is limited by their own knowledge of
legal matter and finances, therefore leaving room for
possible errors. (Morrison, 2010)

6. Surrogate Decision Maker
• A surrogate decision maker is a agent who makes a
choices for a patient when the person is unable to make
them for themselves.
• A surrogate must follow the religious and moral beliefs
when making a choice for the patient.
• “Substituted judgment is a form of surrogate decision
making where the surrogate attempts to establish what
decision the patient would have made if the patient were
competent to do so” (Morrison, 2010).

7. Guardianship and Health Care Proxy
• Guardianship is a process where the court
system declares a patient incompetent for
decision making and a legal guardian is
appointed for managing financial, medical, and
living decisions.
• Health Care Proxy is an appointed person to
make health treatment decisions if the said
person is unable to do so for themselves.
(Morrison, 2010)

8. Legal Rights of The Patient
• The “Patient Self-Determination Act of 1990” protects the
patients right to create an advanced directive and the right to
make health care decisions including right to accept or refuse
certain treatments. (Morrison, 2010)
• “Health care institutions certified by Medicare and/or
Medicaid must take steps to educate all adult patients and the
larger community on their right to accept or refuse medical
care. This law also directs facilities to inquire on admission
whether a patient has made an advance directive, maintain
policies and procedures on advance directives, and provide
this information to patients upon admission. Organizations
must comply with the PSDA in order to receive
reimbursement through the Medicare and Medicaid
programs” (End of life care, 2014)

9. Ethical Issues with Advanced Directives
• Determining that a patient is incompetent to make personal
decisions is one of the first issues when addressing advance
directives. Courts and medical personnel can assist in the
determination of competency to make decisions.
• Ensuring that the patient has made their wishes known and that
others are supportive of the patients choices is a second ethical
hurdle when making life choices . Making sure that when the
patient becomes unable to make choices the advanced directive will
be followed is a top priority.
• When families do not agree with the decisions that the patient or
proxy have made related to health care needs can pose a large
problem for both the patient, healthcare providers and other family
members.
(Lark & Gatti, 1999)

10. Ethical Case Study
• I work at a small community hospital intensive care unit (ICU) and this is a
patient situation that we had come into out unit.
• A 76 year old women who called 911 related to shortness of breath (hx of copd). When
EMS arrived the patient collapsed and was transported to our emergency room(ER).
Once in the ER the patient was in respiratory failure and was orally intubated and
placed on medications that helped to sustain the patients blood pressure and a naso-
gastric tube was placed for gastric evacuation, medications and nutrition if needed.
The patient was stabilized and transferred to my ICU. The patients lives at home and
cares for her husband who is advanced stages of dementia, unfortunately he was
unable to provide any contact information for additional family members at the time of
admission. Once family was contacted they immediately stated that the patient was a
Do Not Resuscitate (DNR) and that she should have never been placed on life support
and they wanted the life support terminated yet they could not provide the hospital
with a advanced directive that outlined the patients wishes. After several days of
family meetings with the medical team (medical doctors, nurses and social services)
the family was being told that she is not terminal and they still insisted on having the
life support stopped against the doctors advice to keep the endo-tracheal tube to allow
the patient to rest and regain pulmonary strength. The family continued to express
that “she would not have wanted this” and the medical doctor decided to allow the
patient to be removed from life support at the request of the family. The patient was
not ready and did not oxygenate well and needed to be placed back on life support in
order to sustain her oxygen levels, the family said no. The patient was placed on BI-
PAP external ventilation and she eventually tired after approximately 10 days she did
succumb to her illness and passed away.

11. References
Advanced Directive. (2015). Retrieved March 18, 2015, from
http://www.winstonmedical.org/PatientsVisitors/AdvancedDirective.aspx
Advance Directives: MedlinePlus. (2014, May 5). Retrieved March 18, 2015,
from http://www.nlm.nih.gov/medlineplus/advancedirectives.html
End of Life Care Manual. (2014). Washington state hospital association,.
Retrieved March 17, 2015, from http://www.wsha.org/eol-fedstate.cfm
Lark, J., & Gatti, C. (1999). Compliance with Advance Directives: Nursing's
View. Critical Care Nursing Quarterly, 22(3), 65-71.
Morrison, E. E. (2010). Ethics in health administration: A practical approach
for decision makers (2nd ed., pp 121-159). Boston: Jones and Bartlett
Publishers