PSDA in the Clinic

A great majority of patients in the ambulatory setting welcome the opportunity to discuss advance planning for health care in case of mental incompetence. While it is commonly assumed that advance planning is relevant for the old or sick alone, planning with young and healthy patients may be considered analogous to screening for illness: the chance of illness is low, but the effort may be worth it. The initiative for advance planning should come from the physician and should be understood to be part of standard care. If a patient has a document already, die physician should review and discuss it, and should recommend a clearer or more specific document if need be. Physicians should see their function as educational, guiding patients to pertinent information (bearin in mind their health status) and asking appropriate questions regarding issues raised in circumstances of life-threatening illness and mental incompetence. Specific preferences should be explored, especially where they are apparently not sensible, to correct misunderstandings or understand atypical values. Irresolvable differences in values between patient and physician that may potentially compromise the physician are indications for asking the patient to agree to transfer of care should the circumstances in question arise. Admission. To the extent that the Patient SelfDetermination Act aims to bring patients' advance directives to the attention of the medical caretakers, admission to a health facility is a practical point at which to do so for a great majority of patients. But whether it is enrolling in a health maintenance organization or arriving in a hospital emergency ward, this time is not likely to be opportune for any substantive discussion of patients' values and treatment preferences. Activities should be restricted to providing informational brochures and identifying resources and to documenting whether the patient has preexisting directives. Role of a health care planning nurse. Ultimately, advance planning should occur in the context of a physician-patient dialogue. However, much of the necessary information and guidance can be provided by a nurse specializing in health care planning, especially if the nurse is provided with a health profile of the patient. Health care planning nurses should be able to inform patients and their families or designated proxies about concepts of advance planning, documents available, basic legal requirements, and so forth; they should be able to guide the patient through tentative completion of a document. They should, however, always seek to involve the physician for the actual completion of the document. Completing die directive. Completing directives in the context of a physician-patient discussion is important for several reasons. Patients can be educated about what decisions are pertinent; they can be provided with illness scenarios and further information; any misconceptions they may hold can be corrected. In helping patients to refine their directives physicians are provided with a unique opportunity to gain insight into the patient's health care goals and values. For a similar understanding, the next of kin or proxy designate should be encouraged to participate in the process of advance planning. What document? Written statements are unlikely to provide for all possible circumstances, and proxy decisions are known to reflect the preferences of the patient poorly

Family medicine · Ethics and Legal Issues in Pediatric Healthcare · Healthcare Decision-Making and Restraints · Medicine · Palliative Care and End-of-Life Issues · Psychology