Advance Directives: Clinical and Philosophical Problems

What Is It? zAdvanced Directive? zAdvance Directive zCore Idea: Making choices in advance

Basic Concept zIdeal way to make treatment decision = autonomous patient chooses zIf patient now incompetent, lacks capacity for autonomous choice zIf decision could have been anticipated, patient could have recorded choice while still capable

Basic Concept z“Carries over” individual autonomy beyond the time when one would normally exercise one’s autonomous capacities zIncreases the number of health care decisions that can be resolved by an appeal to autonomous choice

Types of AD’s z“Living Will” or document-- WHAT zDurable Power of Attorney or health care agent/advocate-- WHO zCombined (e.g., Five Wishes)

“Ideal” AD? zCombined form zDesignates a proxy or agent zContains some instructions to assist agent in knowing and interpreting the person’s wishes

AD: Practical problems zHow many people have them? zDocuments may be hard to interpret zAgent may never have had deep conversation about wishes zAD document may be hard to find when needed zPhysicians may ignore for both good and bad reasons

Reasons to ignore AD zGOOD yClinical situation totally unlike what patient anticipated yEvidence that patient changed mind zBAD yPhysician disagrees with instructions yPhysician fears liability risk y“Son from San Diego” (meddlesome relative)

Ideal AD form zEasy to use and understand zExpresses wishes and values plainly zNon-legalistic-appearing zEncourages conversation within family and with caregivers

Which would you rather have? zNicely filled out form but no conversation? zA lot of conversation within family, members can clearly recall the conversation, but no form?

Why practical problems? zAdvance directive idea is sound; need to educate and persuade public and health care professionals zMaybe the concept has unappreciated weaknesses

Research findings zHow well can families predict wishes of one member? yBest: 60-70% yStill better than physicians zPatients by and large want family members to be their agents

Substituted judgment doctrine zPerson best suited to be proxy decision maker for previously competent but now incompetent person is the one who can best replicate the decision the person would have made, if they were now competent and informed of present status

Whom Do You Want? zYour close relatives zThe infallible (but unrelated) psychic

Possible reasons zI want my family because of process not substance-- who decides for me rather than what they decide zI have a basic distrust of the idea of “preformed values”-- if I’m not in the situation, I am not that confident I know what I would want

Personhood and AD zCantor examples: dementia, loss of memory of previous self zCan some health problems constitute a change in personhood or personal identity? zIf so would that negate the application of Person #1’s advance directive to Person #2?

Personhood zAwareness of self zAwareness of the world zAbility to take some intentional actions zNecessary to have interests: can be helped or harmed for one’s own sake zCan be a person and still be profoundly retarded or demented

The Same Person? zBasic continuity of memory-- I can remember past states as being “me” and recall myself in those previous states zSame network of social relationships zSame physical body