Educating Our Patients about Advance Directives
Recently, a highly publicized case in Florida brought the subject of advance directives to the forefront in the United States. Weeks of extraordinary legal wrangling, attempts to obtain various court orders, and family conflict became very public examples of what can happen in the absence of written advance directives. It appears, however, that some good has already come of this very sad situation: increased public awareness of the importance of advance directives and greater understanding of the scope of the powers such documents can afford patients who are chronically ill or dying. We are well aware that, as individuals age, their ability to make certain decisions may change. This becomes most clear in the context of Alzheimer’s disease and related dementias.
As memory, judgment, reasoning, and executive function and planning decline, patients with dementia lose decision-making capacity in all spheres of life. The ability to drive, manage finances, live without personal assistance, and make medical decisions may be lost. As physicians and health care professionals caring for older adults, we must determine—for medical, ethical, and legal reasons—whether our patients consistently have the capacity for specific types of decision making. Recently, it has become clear that we clinicians need to improve our ability to recognize mental incapacity, given its occurrence in acutely ill medical inpatients and older adults in other care environments.
The usefulness of screening methods for cognitive impairment has been increasingly recognized. Clinicians can help patients take the first step. Advance directives—such as a living will or a durable power of attorney for health care decisions—can go a long way to help our patients receive the level and type of care that they desire from both health care staff and family. A living will enables a competent person to specify the kinds of treatment he or she does or does not want. A living will becomes effective when the patient is terminally ill. Although living wills do not direct our actions in many other clinical situations, they do allow an important starting point for discussion of more specific care issues concerning, for example, the end of life. A durable power of attorney appoints someone, usually a trusted relative or friend, to make health care decisions when the patient cannot. Some older patients may be reluctant to face issues of illness, disability, and death. Others may be unfamiliar with advance directives and/or unaware of their importance. Clinicians should ask their patients if they know about advance directives and whether they have the appropriate documents in place.
If a patient has advance directives, he or she should discuss his or her preferences with the physician. If there are no advance directives, clinicians can begin by educating patients. The American Geriatrics Society’s Foundation for Health in Aging recently launched a website, Aging in the Know: Your Gateway to Health and Aging Resources on the Web (www.healthinaging.org/agingintheknow). Designed for consumers, it offers up-to-date information based on the educational resources of the American Geriatrics Society such as the Geriatrics Review Syllabus (GRS) and Geriatrics At Your Fingertips (GAYF). Aging in the Know translates premier professional education resources on aging for a public audience. Among other things, it can help clinicians find useful resources for their patients about advance directives, choosing a decision maker, and the importance of communicating about end-of-life issues.
Laws about advance directives differ from state to state. Each state has resources for patients and its own forms for living wills and durable power of attorney. Clinicians should reassure their patients that advance directives are not long, complex legal documents requiring expensive legal expertise. Often, the forms are free. There are web-based sources of downloadable legal forms and information for each state. And a patient need not involve an attorney in the process. As health care professionals, we need to view addressing the subject of advance directives as an important part of providing comprehensive care for our older patients.