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Morality of Advanced Directives



 This paper presents an in-depth discussion about the issues 
involved in honoring a patient's advance directive. Ethical 
considerations surrounding the issue as they relate to the nursing 
profession are addressed. The purpose of the paper is to express
an informed position on the issue of honoring a patient's advance 
directive and explore reasons why one may not be honored. The topic 
was chosen on account of personal observation and awareness in an 
acute care setting. The sources used to develop this paper are 
published nursing journals, current books related to this issue, and 
the Internet. The paper concludes with recommendations to assist the 
professional nurse in dealing with issues related to honoring a 
patient's advance directive.

Will Your Advance Directive be Honored?

 Advances in medical technology have done a great deal to 
produce miraculous cures and recoveries. In some circumstances 
however, these advances have created problems for the elderly. More 
aggressive technology approaches are used to extend the life of the 
elderly. On the whole the elderly, as well as others, welcome that
development -- even if they fear some of its consequences. With these 
advances it has become possible to keep people in a vegetative state 
for almost unlimited periods of time. Moreover, there are situations 
in which neither the patient nor the family has the ability to bring 
such unhappy circumstances to an end. For this reason, advance
directives are becoming increasingly prevalent. In a recent study, 
King (1996) reported that approximately 90% of the American public 
want advance directives. Both the young and the healthy express at 
least as much interest in planning as those older than 65 and those in 
fair to poor health (p. 77). According to Lynne (1986) nurses play a
significant role because they attend to the patient continuously and 
have an especially strong claim to be allowed the opportunity to be 
comfortable with the care plan (p. 216). 
 Advance directives, also known as living wills, are documents 
that a person can complete to ensure that health care choices are 
respected. An advance directive only comes into play if a person 
cannot communicate wishes because the person is permanently 
unconscious or mentally incapacitated. A 1991 law called The Patient 
Self Determination Act (PSDA) requires hospitals and nursing homes to 
tell patients about their right to refuse medical treatment. People 
can put anything in their advance directives. Some people list every 
medical intervention they do not want, while others want to make clear 
their request for heroic measures at any cost. It is a way to spell 
out personal wishes. It is crucial that the issue of advance 
directives and the issue of euthanasia not be confused. These issues 
couldn't be more dissimilar. Euthanasia is largely illegal. Advance 
directives are seen as a way to protect one's legal rights for
refusal of treatment. But are advance directives effective in 
achieving the aim intended?
 There is evidence to indicate that advance directives alone 
fall far short of their objective. In a recent study conducted at 
Harvard Medical School, Fishback (1996) reported 66% of all physicians 
interviewed felt there was nothing wrong with overriding a patient's 
advance directive, even if the directive unambiguously stated the 
conditions for the withdraw and withholding of medical treatment. 
Fishback also reported 40% of the physicians questioned chose a level 
of care different from that requested in advance by patients who 
subsequently became incompetent. The physicians interviewed indicated 
that they would only follow a patient's advance directive if it was
consistent with their own clinical judgment. The physicians indicated 
that they wanted to reserve the right to make clinical judgments about 
treatment regardless of a patient's request. In another study, Docker 
(1995) reported on a study where 900 patients were studied over a 
period of ten years. In very few cases did advance directives have 
any influence over decisions to withdraw or withhold life prolonging 
treatment. The passage of the PSDA half way through the study changed 
their effectiveness by barely one percent. A study conducted in the 
state of Utah, among 1398 participants, found little evidence that 
advance directives affect life sustaining treatments (Jacobson,
Kasworm, Baltin, Francis, Green, 1996). Jaffe and Ehrlich (1997) 
report "unfortunately, the advance directive movement has not had 
great success . . . breakdowns occur with alarming frequency in the 
chain of responsibility to observe them" (p. 145). When patients were 
transferred from ambulatory to acute care settings, only 26 percent of 
the patients who had advance directives had them recognized by the 
admitting hospital (Jaffe & Ehrlich, p. 143). 
 These statistics command our attention. They also make us 
focus on the tension and disagreement that exists between physicians 
and their patients. The population clearly seeks more control over 
both their future medical care and also the method, timing, and place 
of their death. Patients want ". . assurance that there will be no 
unreasonable efforts, an affirmation that the dignity to be sought in 
death is the appreciation by others of what one has been in life. . . 
the acceptance of one's own death is a necessary process of nature . . 
."(Nuland, 1993, p. 255). Yet these statistics show that physicians 
often do not allow patient control. How disheartening for a patient
to fear that the doctor cannot be trusted in a matter of such 
importance. It appears that many doctors have no respect for their 
patients' wishes. According to Edwards (1994), nurses as patient 
advocates have a responsibility to make sure patients' wishes are
respected; it is nursing's role to raise informed questions and even 
objections if a patient's treatment violates the patient's wishes. 
Without strenuous interventions to improve the situation, we will have 
expended a vast effort to establish something that basically doesn't 
work. Let's evaluate the reasons for the failure to implement a
patient's advance directive.
 In one study, nurses indicated that family opposition to the 
terms of the advance directive was the primary factor that inhibited 
health care providers from following the patient's living will 
(Weiler, Eland, Buckwater, 1996). When families contradict the
patients wishes, physicians take their views under consideration 
giving them immense weight. After all, who does the physician have to 
answer to? The living, of course. This is why when the family 
disagrees with the advance directive, the family's decisions usually 
win out. Dealing with death and suffering on a daily basis does not 
make it easy for medical professionals to make decisions about 
removing life support. Most make an effort to be as dispassionate as 
possible about such situations so that families can make informed 
decisions. The result is that the profession tends to err on the
conservative side (Edwards).
 Another factor for the failure to follow an advance directive 
was the treating physician's refusal (Weiler et al). One reason for 
the physician's refusal may be reluctance to acknowledge increasing 
patient autonomy. After all, the medical decision horizon looks 
substantially different today than it did just a few years ago. Before 
the 1960's physicians enjoyed a substantial degree of autonomy in 
making treatment decisions for, rather than in conjunction with their 
patients. Unlike in the 1980's and 1990's, where medical decision 
making has become radically transformed from what once was a matter of 
professional concern into what has become a matter of individual
choice. Change is in the air, brought on by forces that have put 
pressure on members of the medical profession to ease their control on 
patient care and treatment decision making. "The days of autonomous 
physician ruling by fiat without much consideration of patients wishes 
are slowly drawing to a close" (Hoefler, 1994, p. 191). According to
Hoefler, "dramatic changes in the medical profession itself have led 
to a breakdown in patient trust". Another reason for their refusal 
may be that it is unmistakably apparent that medical paternalism still 
exists. "A lingering paternalistic attitude on the part of many 
physicians is fostering distrust. If the treatment preferences of 
patients are to be honored, doctors may face the difficult prospect of 
relinquishing, at least in part, this central element of their 
professional role" (King, 1996, p. 51-52). Still another reason
physicians may refuse is a for-your-own-good reasoning. If physicians 
are reluctant to honor patients' choices, they may explain their 
reluctance as a disagreement about whose judgment is better - theirs 
or their patient's (King, p. 52). Also, physicians may give their 
own ethical principals priority when they conflict with patients 
wishes. This is reflected in the following statement by J.M. Hoefler:

 When a patient's advance directive was too restrictive to 
 allow a simple or basic procedure that would yield the patient 
 substantial benefits from the physician's perspective, the 
 physician gave their own ethical principals priority. The 
 reverse may also be true: Despite an advance directive 
 requesting that treatment be provided, physicians may judge 
 that treatment would be of little benefit to the patient in 
 the given circumstances and unilaterally decide to withhold or 
 withdraw treatment. (p. 93) 

Fear of litigation is another factor. Added to the moral, ethical and 
humane considerations, physicians also must keep the legal risks in 
mind. No group is more subject to the risks of litigation than the 
medical profession. The medical professional does not want to be 
accused of pressuring the family for removal of life support, or to
be second guessed by other medical personnel in a court of law. Even 
when advance directives that would seem to protect the physician are 
executed, relieving the physician of some liability, physicians may 
not comply with their patient's wishes (Hoefler, p. 93).
 Uncertainty about the meaning and application of a directive 
is another reason for not implementing an advance directive once it 
has been found and examined. The law on honoring advance directives 
from one state to another is unclear. "Actually the forms are not 
significant legal documents in and of themselves" (Purtilo, 1995, 
p. 132-133). "Even a signed living will could be disqualified if it 
failed the court's measure for being not recent enough, not logically 
consistent, or not specific enough" (Lynn). Interpreting advance 
directives can be problematic at times, as when information is 
lacking, or when a strict reading of the document does not seem to 
make sense. For example, the advance directive may suggest one course 
of care, while the physician and/or family believe the patient would 
in fact have wanted something else. No advance directive can 
anticipate every situation that could possibly arise.
 Emergency circumstances can be another barrier to the 
implementation of advance directives. The emergency room physician 
treating an accident victim is not really in a position to halt things 
immediately when a nurse, looking through the patient's wallet for 
people to contact, finds a living will card. If heroic measures are
applied in an emergency situation, placing the patient on life-support 
systems, it is sometimes very difficult to remove them (King, p. 91).
 Some believe that discussing advance directives upon admission 
to a health care facility is yet another factor. Some would argue that 
this is the wrong place and the wrong time. The PSDA made it necessary 
for every patient to be asked, upon admission to a health care 
institution if they have an advance directive or want to prepare one 
and to supply them with the forms. Many institutions are largely 
paying "lip service" to this matter. "Many institutions, reluctant to 
give the appearance of proselytizing about advance directives, do 
little to initiate discussions with new patients who do not have them" 
(King, p. 110). Many hospital personnel whose job it is to answer 
questions and help patients execute advance directives have 
insufficient training. Perhaps the PSDA needs to be modified. The 
PSDA has, however, increased the public's knowledge. More still needs 
to be done. Why, then, should an information giving requirement 
concerning advance directives be applied not to physicians but to
health care institutions? Most would agree that the outpatient setting 
is the best place and time for such discussion. The physician and 
patient could discuss this issue one to one before an admission to a 
hospital or long term care facility. If advance directives are to 
become an integral part of health care it is essential to implement 
interventions that would make a difference. What can nurses do if they 
believe a patient is being treated contrary to the spirit or letter of 
an advance directive?

According to the American Nurses Association Code of Ethics (ANA, 
 Clients should be as fully involved as possible in the 

 planning and implementation of their own health care. Clients 
 have the moral right to determine what will be done with their 
 own person; to be given accurate information, and all the 
 information necessary for making informed judgments; to be 
 assisted with weighing the benefits and burdens of options in 
 their treatment; to accept, refuse, or terminate treatment 
 without coercion; and to be given necessary emotional support. 
 Each nurse has an obligation to be knowledgeable about the 
 moral and legal rights of all clients and to protect and 
 support those rights.

 Nurses can make sure everyone on the health care team knows 
the document exists, beginning with the physician. Place it in a 
conspicuous position on the patient's chart and label the chart, if 
 State laws may place some restrictions on advance directives 
or a patient may have one from another state. If, after reading an 
advance directive, a nurse is unsure whether it meets the state's 
requirement, the hospital's risk manager, nursing administrator or 
ethics committee should be asked to review the document with the
nurse (Edwards).
 Nurses in the outpatient setting can educate patients to ask 
their physicians to make their advance directive part of their medical 
record, they should keep a copy where it can be found easily and to 
communicate their wishes clearly to their family and physician and be 
sure they are understood.
 Providing psychosocial support for patient and family has 
always been an essential part of nursing. Nurses may well be trusted 
in large part because they are presumed to act in defense of their 
patients lives. Nurses give great importance to the psychosocial 
health of their patients. According to Smith, most professional 
literature related to the psychosocial care of the dying is written by 
nurses. "The dichotomy between nursing and medicine is striking in 
this regard" (Smith, 1985, pg. 284).
 Nurses will undoubtedly, sometime during their career, be 
faced with similar challenges. However, being focused on the nurse's 
most significant role as a patient advocate, will assist the nurse 
when making incisive decisions. 


 American Nurses Association. (1985). American Nurses 
Association Code for Nurses with Interpretive Statements, Section 1.1. 
Washington, DC:ANA.
 Docker, C. (1995). Deciding How We Die. The use Limits of 
Advance Directives. [On-line]. Available: 
 Edwards, Barbara S. (1994). When a living will is ignored. 
American Journal of Nursing, 94(7), 64-5.
 Fishback, R. (1996). Harvard Medical School Division of 
Medical Ethics. Care Near the End of Life. [On-line]. Available: 
 Hoefler, J.M. (1994). Deathright: Culture, Medicine, Politics 
and the Right to Die. Boulder, CO:Westview Press.

 Jacobson, J.A., Kasworm, E., Baltin, M.P., Francis, L.P., & 
Green, D. (1996). Advance directives in Utah. Journal of American 
Medical Association, 156, 1862-1868.
 Jaffe, C., & Ehrlich, C.H. (1997). All Kinds of Love: 
Experiencing Hospice. Amityville, NY:Baywood Publishing.
 King, N. (1996). Making Sense of Advance Directives. 
Washington, DC:Georgetown University Press.
 Lynne, Joanne. (1986). By No Extraordinary Means. Bloomington, 
IN:Indiana University Press.
 Nuland, S.B. (1993). How We Die. New York:Vintage Books.
 Purtilo, R. (1995). Ethical Dimensions in the Health 
Profession. Philadelphia:W.B.Saunders.
 Smith, Walter, J. (1985). Dying in the Human Life Cycle. New 
York:Holt, Rinehart, & Winston.
 Weiler, K., Eland, J., & Buckwater, K.C. (1996). Iowa nurses' 
knowledge of living wills and perceptions of patient autonomy. Journal 
of Professional Nursing, 12(4), 245-252.



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