Advance Directives

The living will, which was adopted by many states in 1990. The treating physician abides by the providions when an ill individual can no longer make competent decisions regarding their medical care. Many living wills are created to ensure that no high-technology life support be used in cases where meaningful recovery will not occur. Durable power of attorney specifies a surrogate decision maker in the event the patient no longer has the capacity to make medical decisions. An advance directive refers to any document stating the patient's wishes in various situations, should the patient be unable to state them in an actual clinical encounter. In 1991, the Federal Patient Self-Determination Act mandated the opportunity to sign an advance directive, for all patients admitted to a hospital. In many cases, the existence of an advance directive can facilitate the implementation of the patient's specific wishes. However, there still exist numerous problems with the widespread implementation of advance directives in the emergency setting, including the fact that very few patients compose them, the designated decision maker may be unavailable, or the advance directive may not reflect a changed opinion. State law often limits advance directives, and patients may lack understanding of decisions and ramifications of the advance directive. Even when an advance directive exists, compliance may be variable, dependent on the clinical circumstances. 20 When an advance directive exists, but is unavailable, the emergency physician must make a decision regarding the reliability of the information available and make every attempt to offer treatment congruent with the patient's previously stated wishes. In the absence of an advance directive, a surrogate may be consulted to aid in the determination of the most appropriate course of action. Decision-making authorities may be a court-appointed guardian, patient-designated decision maker, spouse, adult child (or majority of children available), parents, or the nearest living relative.

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