APRIL 1991, VOL. 53, NO 4 AORN J O U R N A L

Ed it0 ria 1

Learn all you can about an ‘advanced directive’ now

icture this. Your 80-year-old diabetic uncle P has never been hospitalized. One day, he slips on some ice and falls. Neighbors call an ambulance, and he is taken to the nearest hospital for hip x-rays and further evaluation of his diabetes. He is alone, but you are on your way to the hospital to help him. While he is in the admission area, a clerk asks him if he has signed a living will and if he knows he has a right to refuse treatment.

If your uncle is not prepared for that question, he will probably be extremely frightened. He will probably wonder whether he is about to die and if he should hurry up and sign a living will, even though he doesn’t fully understand what that is. Visions of a prolonged death enter his mind. A hurried explanation about the question being merely routine and mandated by Medicare regulations cannot erase the doubts put into his mind. The seed of fear has been planted.

This could happen. Up until now, most hospitals with policies on living wills have taken the passive route by requiring the patient to notify the physician of the existence of the document. But this will change soon. Last year’s budget reconciliation act included essential language from the Patient Self-Determination Act of 1990. The bill requires all hospitals, skilled nursing facilities, home health agencies, and hospice programs to maintain written policies and procedures concern- ing “advance directives,” the collective term that encompasses living wills and durable powers of attorney. The bill also requires such agencies to provide written information to each patient about his or her rights under state law to make decisions

concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to leave written instructions such as a living will or durable power of attorney for health care. The institution will be obliged to provide education for the staff and the community about advance directives. Failure to comply with these requirements would result in loss of Medicare funds for the institution.

I am pleased that the regulations mandate community education. It’s about time. Even though there has been much discussion about living wills in the lay press recently, only 9% of Americans have written one.’ This low percentage probably reflects the lack of opportunity to learn the details of how to execute a living will and what it means to the physicians and nurses delivering care.

Public education about advance directives is a monumental task, one certainly beyond the scope of the community hospital. Nevertheless, educa- tion must begin before a hospital employee is required to ask a patient if he or she has a directive about life-sustaining treatment. It should start now, not a year from now when the regulations are likely to go into effect.

I believe nurses should start educating them- selves now. Part of that education is making a living will. Only then can they begin to teach their families and their patients about the implications of making their wishes known in an advance directive.

If you are like most nurses, you know the basic premise of advance directives and support patient autonomy. Nevertheless, you may not know quite

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enough to discuss an advance directive intelligently or advise patients who may ask basic questions. For example, do you know where to get one or where to keep it? Do you know if such a directive is legal in your state? Are you familiar with the steps necessary to give someone durable power of attorney for health care?

Because the legality of advance medical directives is controlled by the state, the first step in educating yourself is to call your state attorney general. He or she will be able to advise you whether your state law recognizes advance directives, and if it does, whether a specific form is required. Each state’s living-will law or right- to-life law is different. Whether you use a special state-approved document or a simple piece of paper, the task is the same. You must examine your personal, philosophical, and religious views on life and death. You must decide under what conditions life is no longer worth living. And you must clearly record your wishes regarding life- sustaining medical treatment in the event you become severely ill and are unable to make decisions or express your wishes. You and two witnesses then sign it.

Copies should be given to your physician and your next of kin. When you are finished with this process, start to talk to your family members about doing the same.

When everyone becomes educated about advance directives, the mandatory question posed on hospital admission will cease to be frightening. It will be regarded as routine, and it will be asked in the best interest of patients and health care workers alike.

PAT NIESSNER PALMER, RN, MS EDEOR

Note 1. J C Fletcher, “The patient self-determination act:

Yes,” Hastings Center Repor? 20 (September/October 1990) 34.

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