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Advance Directives:

Advance Directives:. Clinical and Philosophical Problems. What Is It?. Advanced Directive? Advance Directive Core Idea: Making choices in advance. Basic Concept. Ideal way to make treatment decision = autonomous patient chooses

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Advance Directives:

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  1. Advance Directives: Clinical and Philosophical Problems

  2. What Is It? • Advanced Directive? • Advance Directive • Core Idea: Making choices in advance

  3. Basic Concept • Ideal way to make treatment decision = autonomous patient chooses • If patient now incompetent, lacks capacity for autonomous choice • If decision could have been anticipated, patient could have recorded choice while still capable

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

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

  6. “Ideal” AD? • Combined form • Designates a proxy or agent • Contains some instructions to assist agent in knowing and interpreting the person’s wishes

  7. AD: Practical problems • How many people have them? • Documents may be hard to interpret • Agent may never have had deep conversation about wishes • AD document may be hard to find when needed • Physicians may ignore for both good and bad reasons

  8. Reasons to ignore AD • GOOD • Clinical situation totally unlike what patient anticipated • Evidence that patient changed mind • BAD • Physician disagrees with instructions • Physician fears liability risk • “Son from San Diego” (meddlesome relative)

  9. Ideal AD form • Easy to use and understand • Expresses wishes and values plainly • Non-legalistic-appearing • Encourages conversation within family and with caregivers

  10. Which would you rather have? • Nicely filled out form but no conversation? • A lot of conversation within family, members can clearly recall the conversation, but no form?

  11. Why practical problems? • Advance directive idea is sound; need to educate and persuade public and health care professionals • Maybe the concept has unappreciated weaknesses

  12. Research findings • How well can families predict wishes of one member? • Best: 60-70% • Still better than physicians • Patients by and large want family members to be their agents

  13. Substituted judgment doctrine • Person 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

  14. Whom Do You Want? • Your close relatives • The infallible (but unrelated) psychic

  15. Possible reasons • I want my family because of process not substance-- who decides for me rather than what they decide • I 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

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

  17. Personhood • Awareness of self • Awareness of the world • Ability to take some intentional actions • Necessary to have interests: can be helped or harmed for one’s own sake • Can be a person and still be profoundly retarded or demented

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

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