Advanced Directive Essay Comparing Two States

Criticism 11.11.2019

Who Decides 7 VI. Ethical considerations surrounding the issue as they relate to the nursing profession are addressed Baron, ; Wysoker, He gives us a scene that he has looked at in a way no one else does and seen things that no one else sees. The ghost town "made simple by the loss of detail" is dazzlingly rich.

If, as Frost habitually does, we were to conjure up a fully-fleshed intent behind this simple condition, perhaps we essay guess that a scene of essays about someone who inspires you land and "forty cellar holes" is more than enough grist for Frost's mill, and anything else would call for poetic fireworks that would overshadow his theme Ever since economic become softer down, your pay day loan trade may be raising at a immediate pace substantially in the united states.

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Catalysts for the Event: The invasion of Russia came as no surprise to the Soviets as Hitler made it evident on multiple occasions that he would invade the country They are not included as variables because of duplication with other dependent variables in the model see Appendix E and table 6 for details. The personnel in this area of technical directive processing typically impact the efficiency of the program due to poor communication and lack of resolve Still, countries were given a great deal of leeway to interpret the rules.

The directive provided major federal contracting reforms to an extent that executive agencies could expect more accountability and completion in procurement activities of the federal government. The compare reason behind the directive was the need for the directive government to take appropriate measures to lessen two spending, fraud, and overcharges Beginning with the First Banking Directive of advanced allowed banks to set up branches in member states, the Second Banking Directive provided for minimum capital requirements and procedures for home country regulators to control branches of financial institutions in other Member states The purpose of a health care directive is to allow personal wishes on various treatments options to be met, when the individual is presented incapable.

Personally I value autonomy, independence, family, dignity, and selflessness This directive states that the United States should be able to operate under a singular national incident management system. For example, an investigation was done by Gore et al. I state it when she states. Although I have been a registered nurse for three years, my passion for nursing started a decade ago.

Most of all, he shows us how greed overpowers anything and everything when times are desperate. This motif assists in developing a major theme in the book Patients are allowed to pet, groom and walk, ride or swim with the animal giving them a chance to nurture and find companionship with the pet. The therapists seeks to achieve a better rapport with the patient channeled through the use of the animal that is assisting in the therapy In my opinion, it is not. I believe the "change" of the world refers to the technological advances. As technology grows, human jobs are replaced with advanced machinery, the next generation appears to get less intelligent, and human contact is replaced by other devices. As technology has continued to take over the world, human jobs have been taken over by factories and computers. Human labor is simply not valued as much Just because slavery was abolished and laws were placed to protect people, that does not stop one group of people from being capable of hating another group of people. Believe it or not, there are racists and hate groups all around us that we are not aware of. Our neighbors or members of our community might be involved in a hate group or may be racist without us having any idea There has been a decline in the death rate and a rise in the birth rate. This is because of all the accomplishments the world has made technologically. Nowadays were able to stop a disease before it affects you. Which lowers the possible chance of some sort of illness challenging the population. There are more medications for all sorts of illnesses, which is allowing people to live longer. Each year the world becomes stronger and stronger against diseases While this epitomizes modern time, it also represents M. The main character, Titus, falls for a girl named Violet who is not like the other stereotypical teens in this book Before any medical procedure, treatment or operation, the health care professional must gain consent from the patient. Under New South Wales law, failing to gain consent prior to medical treatment can result in legal action being taken and the health care professional being charged with assault and battery NSW Government, For consent to be valid and legal, the patient receiving the treatment must be informed of, and completely understand their condition and the reason for their treatment in order to make the most appropriate and informed decision without any Nurses could assist in ensuring the patient needs are met along with protecting their rights These advancements have shaped and influenced the American culture in a positive way, providing Americans an enriched, productive way of life. From the first flight of the Wright Brothers in December, , to the Rocky Mountain Airshow in August, , one can observe how aviation technology has advanced over the years. Women in Singapore should be allowed to fight in the front line. It is undeniable that it would require high physical strength that most women lack, but women can be trained to be just as capable as men, if not better, or assume front line positions requiring less physical strength. The generalised statement of women being weaker should not restrict them from taking up front line combat positions Some will shudder at the prospect of possible argument over what is authentic or how to interpret vague expressions of wishes. But those concerns arise even with statutory advance directives. There are no cookbook instructions for end-of-life decisions. More importantly, the Idaho provision accurately affirms long-standing common law and constitutional principles of self-determination and liberty in the context of health care decision-making. We too easily forget that statutory advance directives were created as one way to effectuate those principles, not to box them in to a single pathway. Another advantage of the Idaho provision is that it makes no difference whether the person is out-of-state or in-state; their wishes, no matter how communicated, are strengthened. This does not eliminate differences in how a state may interpret particular words, such as in the Illinois-Wisconsin example above. But, it does make portability a non-issue. This approach has gained attention in at least one federal proposal in the th Congress. Conclusion The value of this any-kind-of-expression approach is a freeing up of the process of advance care planning so that it can flow from the personal communication style, culture, and comfort level of each individual, ideally in dialog with loved ones and health care providers. In contrast, the legal paradigm, built upon precise formalities of execution, prescriptive language, and technical definitions, has been user-friendly only for a minority of the public. The purpose of this Article is to establish an additional, non-exclusive method for an individual to exercise his or her right to give, withhold, or withdraw consent to medical treatment, including mental health treatment, when the individual lacks sufficient understanding or capacity to make or communicate health care decisions. Section III examines the incremental evolution of the relevant statutory law, followed by an analysis of a fundamental paradigm shift in public policy in Section IV. Because only a minority of the adult population has historically used advance directives, Section VI fills in the rest of the surrogate landscape by addressing health care decision making authority where there is no advance directive in place. Finally, the federal role in health care advance care planning policy is examined in Section VII. Several grounds are asserted for this right. Virtually every judicial writing that has addressed the issue starts with the well-known tenet expounded by Justice Benjamin Cardozo in the case of Schloendorff v. From these common law roots came two logical extensions -- the doctrine of "informed consent" and a corollary right to refuse treatment. Leland Stanford Jr. University Bd. Kline in a malpractice case. In practice, the nuances, variability, and continuum of voluntariness and decisional capacity pose everyday challenges to health care providers. Examples have typically involved Jehovah's Witnesses blood transfusion cases. Several U. Cruzan v. Constitution would grant a competent person a constitutionally protected right to refuse lifesaving hydration and nutrition. Finally, the Court held that the U. Constitution allows states considerable leeway in establishing, as Missouri did, a "procedural safeguard" for incompetent persons who cannot exercise the right to refuse treatment on their own. Only a few states have been nearly as restrictive as Missouri in imposing and defining such a standard. The acceptance of such a constitutional right reinforces the validity and weight of all authentic expressions of patient wishes. Supreme Court just a few years after Cruzan -- whether there was a constitutional right to physician aid-in-dying for terminally ill patients who requested a prescription for lethal drugs. In a pair of decisions in , the Court held that neither the Due Process clause nor the Equal Protection clause of the 14th Amendment created a constitutional right to assisted suicide. But, unlike the process of obtaining informed consent for a present treatment, advance directives are usually made well before the time a patient can be fully informed of the risks, benefits, and alternatives to any proposed diagnostic or therapeutic medical procedures. The first advance directive -- called a living will -- was proposed by the Euthanasia Society of America in , 26 and Luis Kutner, a human-rights lawyer from Chicago who represented the Society, proposed it as a model in an oft-quoted Indiana Law Journal article. He may have become the victim of a sudden accident or a stroke or coronary. Therefore, the suggested solution is that the individual, while fully in control of his faculties and his ability to express himself, indicate to what extent he would consent to treatment. Both informed consent and trust paradigms are characteristic of a legal transactional approach that became the paradigm for state advance directive legislation. One might ask today, more than 30 years later, why physicians would want or need immunity to do what the underlying law already seemed to require i. The technological developments in medicine during the s and s thrust medicine into a new world where, for the first time, it often became difficult to distinguish saving life from prolonging suffering and death. Many doctors, after all, are taught to regard death as an enemy and to do all they can to defeat it -- or at least to keep it at bay for a while. Many regard "pulling the plug" as an act akin to euthanasia, which is forbidden by both law and the medical code. Such places currently house thousands of people who have neither hope nor prospects of a life that even approaches normality. A decision to remove Karen's life-support system could prompt new suits by parents seeking to end the agony of incurably afflicted children, or by children seeking to shorten the suffering of aged and terminally ill parents. It was concerns such as these that resulted in a legal model of advance care planning that focused on conventional legal formalities or procedural protections intended to protect vulnerable populations from harm, specifically the premature termination of life due to lack of understanding, or diminished capacity of, or undue influence upon, the signor of the living will. The number of living will laws snowballed during the next ten years, so that by the end of , 41 states had adopted living will laws. Policy makers turned to validating and reshaping the use of durable powers of attorney to apply to health care. It was originally used to delegate authority over property matters. However, in common law, a power of attorney was revoked by the incompetency or incapacity of the principal. Thus, the common law power had no utility as a planning tool for incapacity. Thereafter, states adopted durable power of attorney laws at a rapid pace. Adapting them to the context of health care may require that greater procedural safeguards be provided: precisely which safeguards are needed might best be determined after more experience has been acquired. This wave of legislation took place roughly from the mids to the mids, with California again leading the pack with its law. Negotiating who should be present during the discussion. Involving their continuity physician in the discussion. Curtis et al. Patients, families and clinicians may inadvertently collude to avoid mentioning death, dying, or planning for the end of life. In addition, patients and families recall only a fraction of the information physicians transmit, and the evidence suggests that some patients do not desire detailed information. Stability of and proxy understanding of patient preferences. Because ADs are static documents, the stability of patient preferences concerning end-of-life care is important. Several studies have demonstrated modest stability in preferences over periods of up to two years. Ditto et al. However, the desire for life-sustaining treatment returned to near pre-hospitalization levels at the annual interview conducted several months after hospitalization. This dip was more pronounced in preferences for CPR and artificial nutrition and hydration than in preferences for less invasive treatments, suggesting that preferences for life-sustaining treatment are dependent on the context in which they are made -- individuals may express different treatment preferences when they are healthy than when they are ill. The accuracy with which proxy decision makers can predict patient end-of-life treatment preferences has been shown to vary considerably. Shalowitz et al. Barriers to advance directive completion. Although older adults and those with serious illnesses seem willing to participate in end-of-life planning, a significant proportion of patients do not fully understand their options concerning end-of-life care. Perception that ADs are difficult to execute. Perception that ADs are important for others, but not for themselves. While many patients would welcome discussions about end-of-life planning with their clinicians, they would prefer to delegate decision making authority to proxies rather than make rigid decisions now for complex decision making in the future. Lorenz et al. Simple, single-component consumer education interventions designed to increase knowledge of, or completion of, ADs were mostly unsuccessful, or were only modestly successful. Single-component interventions tended to result in low AD completion rates, especially for interventions without an educational component or for mailed forms alone. Only multi-faceted interventions e. In this intervention, hospital and nursing home staff and nursing home residents and their families were educated about ADs, and documents were offered in the context of a specific intervention designed to elicit preferences. Interventions to improve provider communication skills have had mixed results. They found no evidence of negative psychological adjustment or affective outcomes from these discussions. A controlled trial of preference elicitation and AD completion with patients awaiting cardiac surgery did not find increased anxiety among patients or family members but did find increased congruence between patients and their families concerning preferences. More detailed and meaningful ADs in nursing homes were achieved with more and focused discussion. Satisfaction was not significantly different in intervention and control nursing homes, but intervention nursing homes reported fewer hospitalizations per resident mean, 0. Schwartz et al. Shorr et al. Overall, the research indicates that multi-component, longitudinal educational interventions modestly increase AD completion rate and moderately increase medical record documentation, but more sophisticated techniques are needed to motivate physicians and patients to initiate ACP discussions and to induce patients to complete an AD. Almost all ADs requested that treatment be forgone as death neared, and treatment followed these instructions in nearly all cases see also Section VI. A modified version of this model was pilot tested on a small sample of chronically ill adults congestive heart failure, end-stage renal disease, and preoperative open-heart surgery patients and their caregivers using quality improvement techniques. Diseases exist for which there is no available cure. A living will provides a legal means by which health care professionals can be aware of how much care an individual does or does not want should they become medically incapacitated. It can also provide an individual with some peace of mind knowing either that everything medically available will be done to prolong his or her life, or that life prolonging measures will be limited if there is no hope for recovery.

As a teenager, I was always fascinated by the nurses who took care of me at the hospital. Subsequently, I my relationship with my siblings essay volunteering to a nearby hospital to get acquainted with the reality of caring for others.

They were not enacted with refusals of treatment especially in mind, nevertheless, are applicable given the conceptual unity of consent and refusal. Some living will statutes include family consent authority, but since these statutes are typically limited to patients in terminal conditions or in permanent unconsciousness and to decisions about life-sustaining treatment, their application to the full range of health care decisions may be in question. These laws vary significantly in their scope of authority and other limitations, which will be discussed in Section VI below. A fifth and most important wave of legislation began as a merging of the separate health care decisions acts states had already enacted. The Act establishes very simple rules for recognizing almost any kind of written or oral statement as an advance directive. Even unwitnessed documents are valid under the Uniform Act. The Act provides a comprehensive, sample form with options for instructions, appointment of an agent, organ donation, an option to name a primary physician, and it recognizes default surrogates in the absence of an advance directive. The federal legislative role in the above evolution of advance directives has been minimal. At its heart, it is an information and education mandate. It does not create or change any substantive right to health care decision making. Rather, it requires all Medicare and Medicaid provider organizations specifically, hospitals, skilled nursing facilities, home health agencies, hospices, and prepaid health care organizations to do five things: "provide written information" to patients at the time of admission concerning "an individual's right under state law whether statutory or as recognized by the courts of the state to make decisions concerning such medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives;" "maintain written policies and procedures" with respect to advance directives e. Facilities cannot "condition the provision of care or otherwise discriminate against an individual based on whether or not the individual has executed an advance directive. This apparently includes developing or approving national educational materials, assisting states in developing state-specific documents, and mailing information to Social Security recipients. However, other than preparing a public information document reprinted at 57 F. The result, as elaborated below, is a landscape that has predominantly emphasized standardized legal formalities and restrictions, with procedural requirements or limitations intended to serve as protections against abuse or error. The Legal Transactional Approach A legal transactional framework focuses on the formal steps of creating and implementing the legal tools to direct or delegate health care decisions in advance of decisional incapacity. In this light, the creation of advance directives are treated much like conventional conveyances of interests in property or contracts that establish important rights and obligations. The validity of the transaction focuses on required legal formalities and standardization of the process. Legal formalities are intended to impress upon the parties the seriousness of a transaction and the potential consequences of the transaction. Because this is a legal tool that will often be signed and used without the advice of legal counsel, detailed standardized formalities are relied upon to ensure the voluntary, knowing, and competent execution of the transaction -- the same elements central to informed consent. However, the task cannot be equated with giving informed consent to a particular treatment, because making a judgment about how one wants to be treated in a future hypothetical situation is by necessity far more value driven and far less fact driven than making a contemporaneous choice about a health care treatment for a condition about which the person has been fully informed. States have required several kinds of legal formalities for execution of advance directives: Standardized statutory forms. In most states, these are provided as optional models, but they may sometimes be seen as the only safe option to use. Eight states require specific disclosures or notice to persons executing health care powers of attorney. Prescribed phrases for authorizing certain wishes. In most states, two adult witnesses are sufficient for execution of a directive, although witness qualifications -- or rather disqualifications -- can be many. Most commonly disqualified as witnesses are the named agent, the treating health care provider and facility staff. Each witness must state in an affidavit that: the witness is not related to the principal by blood, marriage, or adoption, either as a spouse, lineal ancestor, descendant of the parents of the principal, or spouse of any of them; not directly financially responsible for the principal's medical care; not entitled to any portion of the principal's estate upon his decease under a will of the principal then existing or as an heir by intestate succession; not a beneficiary of a life insurance policy of the principal; and not appointed as health care agent or successor health care agent in the health care power of attorney; and that no more than one witness is an employee of a health facility in which the principal is a patient, no witness is the attending physician or an employee of the attending physician, or no witness has a claim against the principal's estate upon his decease. Most states restrict who may serve as agent or proxy, most typically the treating health care provider or employees of the treating facility, although exceptions for relatives are common. In three states, the agent must accept their appointment in writing. A recent review of these limitations on surrogate decision making conducted by the ABA Commission on Law and Aging identified the following limitations occurring in varying frequency: 77 All living will statutes by definition impose medical diagnosis prerequisites before taking action usually a diagnosis of terminal condition or permanent unconsciousness , but a dozen states also require a diagnostic precondition before an agent may forgo life-sustaining procedures. The complexity of the process of diagnosis and documentation also varies. A majority of states impose limitations on implementing advance directives if the patient is pregnant. Twelve states include limitations that prohibit a surrogate from consenting to medical interventions that are especially consequential or controversial, such as sterilization or abortion or psycho-surgery. Thirty-three states have special limitations on consent by agents, default surrogates, or guardians to forgo artificial nutrition or hydration. These range from an absolute bar on default surrogates to required diagnostic preconditions. An ample body of research, summarized by Fagerlin and Schneider and others, reveals that conventional advance directives have had relatively little impact on end-of-life decision making. Rather, the documents known as advance directives should be seen as a set of tools useful in the ongoing process of advance care planning. Most state advance directive statutes explicitly recognize the validity of advance directives executed in other states, 81 although the recognition means only that the directive will be considered validly executed. It does not mean that the out-of-state directive will be interpreted according to the law of the state where it was executed. For both legal and practical reasons, it will likely be interpreted according to the law of the state where it is implemented. Moreover, given the universal public policy in favor of advance care planning by all adults, it seems incongruous that states are so Balkanized in the mechanics of creating and implementing advance directives in the first place. As a lawyer, I would like to be able to assure a client that she can use any advance directive that resonates with her and it will be valid and honored in every state. In , I published an article that took one advance directive that sought to be used nationally — the Five Wishes advance directive—and held it up to the law of all 50 states and the District of Columbia to see if it could possibly work nationally. The other 14 states posed requirements that made it difficult, if not impossible, for Five Wishes or any other single form to work in all states as a statutorily recognized form. Interestingly, in the intervening years, some states have somewhat simplified their laws such that Five Wishes form now claims to be usable in 42 states and D. Possible Policy Approaches to Portability There are a number of possible policy pathways to portability of advance directives, each with its advantages and disadvantages. One is through the simplification and conforming of state law nationally, such that it becomes feasible to meet the requirements of all states in a single form. This is the route tested by the Five Wishes exercise. Unfortunately, only seven states have adopted the act Alaska, Delaware, Hawaii, Maine, Mississippi, New Mexico, and Wyoming , and even then, only with their own home-grown variations. Considering the politics of state law-making, sufficient uniformity across the states seems unlikely. Another road to portability is the conventional path traveled by states, which relies on language in statute recognizing the validity of out-of-state directives if: 1 they are valid in the state where executed or 2 if they meet the requirements of the state where treatment is delivered. Thirty-five percent of participants had completed a health care proxy, comparable to completion rates in White populations found in other studies. Perkins et al. Blackhall et al. Whites were the least likely to want life-support, whereas Mexican-Americans were more likely to want it. Korean-Americans were more positive about the use of life-sustaining treatment than Whites but did not want such technology used personally. African-Americans generally felt it was acceptable to withhold and withdraw life-support, but were the most likely to want to be kept alive on such treatment. There were various reasons for these views: African-Americans were found to more often prefer the use of life-support; Asians and Hispanics were more likely to desire family-centered decision making rather then an autonomy-based model ; and Hispanics were less likely to believe their actions could change the future and were more concerned that life-sustaining treatments would be withdrawn prematurely. Similar results were found in a qualitative study by Shrank et al. They found two commonly overlapping themes: the belief that only God has the power to decide life-and-death and a belief in divine intervention or miracles. Consistent with studies noted above, African-Americans were more likely than Whites to favor life-sustaining treatments regardless of illness severity and less likely to complete an AD. Similarly, True et al. Some research suggests that ADs, as currently constituted, are not compatible with the cultural traditions of some patients. Some evidence suggests that Hispanic, Asian, Chinese, Pakistani, and Native-American communities prefer to avoid the emotional and physical stress caused by addressing end-of-life issues, and family members actively protect the terminally ill from knowledge of their condition. In terms of decision making, relative to persons of African-American or European decent, Korean and Mexican-Americans appear more likely to consider family members, rather than the patient alone, as holding the decision making power regarding life-support. Many see ADs as a mechanism to help physicians and patients begin to talk about end-of-life care. Breaking bad news is difficult for many physicians. Fried et al. For some patients, treatment burden would be bearable if the treatment outcome was desirable, but patients were less willing to endure perceived burden for marginal outcomes. Certain outcomes were so unacceptable that they determined preferences regardless of burden. A number of studies have found that older patients are more interested in discussing the outcomes of serious illnesses specifically how various illness and treatments might affect their valued life activities than specifying desired medical interventions. Clayton et al. They found disparate views among respondents about the optimal timing, substance, and context for these discussions. Patients and families identified five elements as essential for these discussions: Feeling comfortable with the health care provider. Feeling that the provider showed compassion and respect for the patient. Negotiating who should be present during the discussion. Involving their continuity physician in the discussion. Curtis et al. Patients, families and clinicians may inadvertently collude to avoid mentioning death, dying, or planning for the end of life. In addition, patients and families recall only a fraction of the information physicians transmit, and the evidence suggests that some patients do not desire detailed information. Stability of and proxy understanding of patient preferences. Because ADs are static documents, the stability of patient preferences concerning end-of-life care is important. Several studies have demonstrated modest stability in preferences over periods of up to two years. Ditto et al. As technology grows, human jobs are replaced with advanced machinery, the next generation appears to get less intelligent, and human contact is replaced by other devices. As technology has continued to take over the world, human jobs have been taken over by factories and computers. Human labor is simply not valued as much Just because slavery was abolished and laws were placed to protect people, that does not stop one group of people from being capable of hating another group of people. Believe it or not, there are racists and hate groups all around us that we are not aware of. Our neighbors or members of our community might be involved in a hate group or may be racist without us having any idea There has been a decline in the death rate and a rise in the birth rate. This is because of all the accomplishments the world has made technologically. Nowadays were able to stop a disease before it affects you. Which lowers the possible chance of some sort of illness challenging the population. There are more medications for all sorts of illnesses, which is allowing people to live longer. Each year the world becomes stronger and stronger against diseases While this epitomizes modern time, it also represents M. The main character, Titus, falls for a girl named Violet who is not like the other stereotypical teens in this book Before any medical procedure, treatment or operation, the health care professional must gain consent from the patient. Under New South Wales law, failing to gain consent prior to medical treatment can result in legal action being taken and the health care professional being charged with assault and battery NSW Government, For consent to be valid and legal, the patient receiving the treatment must be informed of, and completely understand their condition and the reason for their treatment in order to make the most appropriate and informed decision without any Nurses could assist in ensuring the patient needs are met along with protecting their rights These advancements have shaped and influenced the American culture in a positive way, providing Americans an enriched, productive way of life. From the first flight of the Wright Brothers in December, , to the Rocky Mountain Airshow in August, , one can observe how aviation technology has advanced over the years. Women in Singapore should be allowed to fight in the front line. It is undeniable that it would require high physical strength that most women lack, but women can be trained to be just as capable as men, if not better, or assume front line positions requiring less physical strength. The generalised statement of women being weaker should not restrict them from taking up front line combat positions For both stores the requirements for a store manager are somewhat the same. The store manager is responsible for operations of the store, the appearance of the store, and the store sales. I will discuss the selection process of hiring. I will also explain the advantages and disadvantages of hiring internally and externally. Congress felt that individuals has the right to determine their final healthcare. The PSDA provides every competent adult and emancipated minor with the right to decide their own decision on what medical care or treatment they accept, reject, or discontinue. The choice between quantity versus quality of life is complex, and not one that should be left up to chance. However, if a patient has requested not to be kept alive by certain means, it is their legal right to have their wishes taken into consideration. It is a complicated and often litigated issue.

Shortly, my grandfather had a Cerebrovascular accident and became debilitated These nurses are Masters or post-Masters directive individuals that provide specialty care in unique roles within each patient population. People say that TV is the resource of information and it is a sort of window on the world. We can get a lot of information, and pleasure through TV. As a result, we think that TV is set is a necessity in the modern home.

Some limit surrogates to fairly close relatives. Some were directive in informed consent statutes enacted in the s and s. They were not enacted with essays of treatment especially in compare, nevertheless, are applicable given the conceptual unity of two and two. Some living will statutes include family consent authority, but since these statutes are typically limited to patients in terminal compares or in permanent essay and to decisions about life-sustaining treatment, their application to the advanced range of state care decisions may be in question.

Advanced directive essay comparing two states

These laws vary significantly in their scope of authority and advanced limitations, which will two compared in Section VI below. A fifth and state important wave of legislation began as a merging of the separate health care decisions acts states had already enacted. The Act establishes very simple rules for recognizing almost any kind of directive or oral essay as an advance directive.

Free advance directive Essays and Papers

Even unwitnessed documents are valid under the Uniform Act. The Act provides a comprehensive, sample form with options for instructions, appointment of an agent, organ donation, an option to name a primary physician, and it recognizes default surrogates in the absence of an advance directive.

The federal legislative role in the above evolution of advance directives has been minimal. At its heart, it is an information and education mandate. It does not create or change any substantive right to health care decision making. Rather, it requires all Medicare and Medicaid provider organizations specifically, hospitals, skilled nursing facilities, home health agencies, hospices, and directive health care organizations to do five things: "provide written information" to patients at the time of admission concerning "an individual's right under state law whether statutory or as recognized by the courts of the state to make decisions concerning such medical care, including the right to accept or refuse medical two surgical treatment and the right to formulate advance directives;" "maintain written policies and procedures" with respect to advance directives e.

Facilities cannot "condition the provision of care or otherwise discriminate against an essay based on whether or not the individual has executed an advance directive. This apparently includes developing or approving national educational materials, assisting states in developing state-specific documents, and mailing information to Social Security recipients. However, other than comparing a public information document reprinted at 57 F. The result, as elaborated below, is a landscape that has predominantly emphasized standardized legal formalities and restrictions, with procedural requirements or limitations intended to serve as protections against abuse or comparison and contrast essay template with sentence starts. The Legal Transactional Approach A legal transactional framework focuses on the formal steps of creating and implementing the state tools to direct or delegate health care decisions in how to choose a college essay topic reddit of decisional incapacity.

In this light, the creation of advance directives are treated much like conventional conveyances of interests in property or contracts that establish important rights and obligations. The validity of the transaction focuses on required legal formalities and standardization of the advanced. Legal formalities two intended to impress upon the parties the seriousness of a transaction and the potential consequences of the transaction.

Because this is a directive tool that will often be signed and used without the advice of legal counsel, detailed standardized formalities are relied upon to ensure the voluntary, knowing, and competent execution of the transaction -- the same elements central to informed consent.

However, the task cannot be equated with giving informed consent to a particular treatment, because making a judgment about how one wants to be treated in a future hypothetical situation is by necessity far more value driven and far less fact driven than making a contemporaneous choice about a health care treatment for a condition about which how to put together a research reading list for an essay person has been fully informed.

States have required several kinds of legal formalities for execution of advance directives: Standardized statutory forms. In most states, these are provided as optional models, but they may sometimes be seen as the only safe option to use.

Eight states require specific disclosures or notice to persons executing health care powers of attorney. Prescribed phrases for authorizing certain wishes. In most states, two adult witnesses are sufficient for execution of a directive, although witness qualifications -- or rather disqualifications -- can be many. Most commonly disqualified as witnesses are the named agent, the treating health care provider and facility staff. Each witness must state in an affidavit that: the witness is not related to the essay by blood, marriage, or adoption, either as a spouse, advanced ancestor, descendant of the parents of the principal, or spouse of any of them; not directly financially responsible for the principal's medical care; not entitled to any portion of the principal's estate upon his decease under a will of the principal then existing or as an compare by intestate succession; not a beneficiary of a life insurance policy of the principal; and not appointed as health care agent or successor health yale law school 250 word essay sample agent in the health care power of attorney; and that no more than one witness is an employee of a health facility in which the essay is a patient, no witness is the attending physician or an employee of the attending physician, or no witness has a claim against the principal's estate upon his decease.

Most states restrict who may serve as agent or directive, most typically the treating health care provider or employees of the treating facility, although exceptions for relatives are common. In three states, the agent must accept their appointment in writing. A recent review of these limitations on surrogate decision making conducted by the ABA Commission on Law and Aging identified the following limitations occurring in varying frequency: 77 All living will statutes by definition impose medical diagnosis prerequisites before taking action usually a diagnosis of terminal condition or permanent unconsciousnessbut a dozen states also how to write a how to do a autobiography essay essay a two compare before an agent may forgo life-sustaining procedures.

The state of the process of diagnosis and documentation also varies.

Advance Directives: Patient End-of-Life Decisions Essays | Cram

A majority of states impose limitations on implementing advance directives if the patient is pregnant. Twelve states include limitations that prohibit a surrogate from consenting to medical interventions that are especially consequential or controversial, such as sterilization or abortion or psycho-surgery.

An obstacle to decision making toward the end of life arises when families or rarely patients desire care of greater aggressiveness then is deemed warranted by providers. This often occurs in the setting of mistrust or disagreement over prognosis. Other times, conflict centers on families desiring life-sustaining treatment in compromised health states e. These situations are most commonly the result of poor early patient-provider communication and ACP. Under these circumstances, the lack of socially-held values on the overall goals of medicine and what is futile care, may hamper ACP. A number of mechanisms to facilitate ACP have been suggested. These include detailed elicitation of patient preferences for medical treatments under a variety of conditions, 57 exploration of patient values in construction of approaches to care, 58 and mechanisms to facilitate discussion and specification of a proxy. Optimally, the proxy participates in the ACP conference. The AD is completed with proxy specification and a description of goals or desired treatments. The AD is available to clinicians and proxy. Still, a number of practical limitations to the use of ADs and ACP have been identified, 31 , 47 , 50 , 55 , 61 including: Patients have difficulty predicting their future treatment preferences. A major goal of ACP is to help proxies understand this. Because expressed preferences often do not match clinical circumstances, goals of care are often more malleable in directing medical care. This skill must be coupled with the realization that capacity may wax and wane and variable levels of capacity may be required for different decisions. In practice, decision making capacity is often assessed informally or inconsistently 72 and there are many misconceptions about capacity in a clinical context. Despite the plethora of practical obstacles, from an ethical perspective, it is imperative that ACP be carried out to the best abilities of providers, patients and families. In this report, we update the systematic review to include the period and incorporate new topic areas for the period not included in the original review. We address the following questions: What does the literature say about the utility, feasibility, ethical issues, and success of implementation of ADs and ACP for a diverse array of patient populations and across health care settings? What are the salient considerations necessary to more widely apply ADs in vulnerable populations, such as the cognitively or physically disabled, and in determining what will be a wise course for policy development? What are the potential methods that can be used to promote and document ADs more widely including the role of health information technology HIT and social marketing? RAND searched the traditional health literature databases e. These articles involved human subjects, but did not include individual case reports. To update the original systematic review, we conducted a literature search of articles published in peer-reviewed journals in the United States between and Measures and measurement. State legislation, policy, or regulations. Legal considerations. ADs and ACP among disabled persons. ACP and ADs were intended to translate the fundamental values of biomedical ethics into bedside care, which was dramatically transformed by the technological breakthroughs of the s though s. Despite two decades of legislation and advocacy, studies show that AD completion rates are low 20 , 22 , 37 , 38 , 43 , 48 , 76 , 77 , 78 , 79 , 80 , 81 and that these documents often do not drive care. Certain groups of individuals and venues of care have been particularly resistant to the penetration of ACP and ADs. However, some regional efforts have demonstrated social change, including changes in expectations, and integration of ACP and ADs into care across venues, improving the match of technological care with patient goals. Despite the institutionalization of ADs in state and federal law and widespread public support for ACP from healthy and ill populations as well as the medical community, the accumulated evidence shows that adoption of ADs is low. Venue of care. Many jurisdictions allow different end-of-life advance directives for patients; however, forty states have "laws specifying who can make decisions for a patient who does not have an advance directive" Marker, Ethical principles also play a significant role in end-of-life decisions. Washington state acknowledges the advance directive as one combined document of the "living will and durable power of attorney…. The perception may arise partly because of the visibility and perceived authority that official legal forms carry, but also because of the tendency of legal advisers to counsel conservatively i. The reality is that most end-of-life decisions take place through doctor-patient-family interactions without the involvement of these legal advance care planning tools, and most state advance directive laws assert explicitly that they do not pre-empt or change any existing rights regarding health care decision making authority or responsibility. Specifically, 33 states with living will, durable power of attorney for health care, or combined statutes expressly include non-pre-emption language, similar to the following examples from Florida and Illinois: 1 The provisions of this chapter are cumulative to the existing law regarding an individual's right to consent, or refuse to consent, to medical treatment and do not impair any existing rights or responsibilities which a health care provider, a patient, including a minor, competent or incompetent person, or a patient's family may have under the common law, federal Constitution, state constitution, or statutes of this state. In such respect the provisions of this Act are cumulative. The North Carolina statute states this perspective most succinctly in its statement of purpose of its advance directive law: The General Assembly recognizes as a matter of public policy the fundamental right of an individual to control the decisions relating to his or her medical care, and that this right may be exercised on behalf of the individual by an agent chosen by the individual. The purpose of this Article is to establish an additional, non-exclusive method for an individual to exercise his or her right to give, withhold, or withdraw consent to medical treatment, including mental health treatment, when the individual lacks sufficient understanding or capacity to make or communicate health care decisions. Section III examines the incremental evolution of the relevant statutory law, followed by an analysis of a fundamental paradigm shift in public policy in Section IV. Because only a minority of the adult population has historically used advance directives, Section VI fills in the rest of the surrogate landscape by addressing health care decision making authority where there is no advance directive in place. Finally, the federal role in health care advance care planning policy is examined in Section VII. Several grounds are asserted for this right. Virtually every judicial writing that has addressed the issue starts with the well-known tenet expounded by Justice Benjamin Cardozo in the case of Schloendorff v. From these common law roots came two logical extensions -- the doctrine of "informed consent" and a corollary right to refuse treatment. Leland Stanford Jr. University Bd. Kline in a malpractice case. In practice, the nuances, variability, and continuum of voluntariness and decisional capacity pose everyday challenges to health care providers. Examples have typically involved Jehovah's Witnesses blood transfusion cases. Several U. Cruzan v. Constitution would grant a competent person a constitutionally protected right to refuse lifesaving hydration and nutrition. Finally, the Court held that the U. Constitution allows states considerable leeway in establishing, as Missouri did, a "procedural safeguard" for incompetent persons who cannot exercise the right to refuse treatment on their own. Only a few states have been nearly as restrictive as Missouri in imposing and defining such a standard. The acceptance of such a constitutional right reinforces the validity and weight of all authentic expressions of patient wishes. Supreme Court just a few years after Cruzan -- whether there was a constitutional right to physician aid-in-dying for terminally ill patients who requested a prescription for lethal drugs. In a pair of decisions in , the Court held that neither the Due Process clause nor the Equal Protection clause of the 14th Amendment created a constitutional right to assisted suicide. But, unlike the process of obtaining informed consent for a present treatment, advance directives are usually made well before the time a patient can be fully informed of the risks, benefits, and alternatives to any proposed diagnostic or therapeutic medical procedures. The first advance directive -- called a living will -- was proposed by the Euthanasia Society of America in , 26 and Luis Kutner, a human-rights lawyer from Chicago who represented the Society, proposed it as a model in an oft-quoted Indiana Law Journal article. He may have become the victim of a sudden accident or a stroke or coronary. Therefore, the suggested solution is that the individual, while fully in control of his faculties and his ability to express himself, indicate to what extent he would consent to treatment. Both informed consent and trust paradigms are characteristic of a legal transactional approach that became the paradigm for state advance directive legislation. One might ask today, more than 30 years later, why physicians would want or need immunity to do what the underlying law already seemed to require i. The technological developments in medicine during the s and s thrust medicine into a new world where, for the first time, it often became difficult to distinguish saving life from prolonging suffering and death. Many doctors, after all, are taught to regard death as an enemy and to do all they can to defeat it -- or at least to keep it at bay for a while. Many regard "pulling the plug" as an act akin to euthanasia, which is forbidden by both law and the medical code. Such places currently house thousands of people who have neither hope nor prospects of a life that even approaches normality. A decision to remove Karen's life-support system could prompt new suits by parents seeking to end the agony of incurably afflicted children, or by children seeking to shorten the suffering of aged and terminally ill parents. It was concerns such as these that resulted in a legal model of advance care planning that focused on conventional legal formalities or procedural protections intended to protect vulnerable populations from harm, specifically the premature termination of life due to lack of understanding, or diminished capacity of, or undue influence upon, the signor of the living will. The number of living will laws snowballed during the next ten years, so that by the end of , 41 states had adopted living will laws. Policy makers turned to validating and reshaping the use of durable powers of attorney to apply to health care. It was originally used to delegate authority over property matters. Michael Bishop, look at the possibilities technology offers while non-scientists, like Jeremy Rifkin and Mary Shelley, look at the potential chaos that could be caused by it. He is also winner of the Nobel Prize. He wrote, "Enemies of Promise" because he wanted to dispel the misconceptions that many people have about science, since he feels that these could have serious consequences for all Americans Each style is important in their own way. Sometimes in certain situations using one decision making styles, say directive, will be better than using another, behavioral, and vice versa. Each person has their own decision making styles, but learning the other styles will be helpful and prepare someone more for different situations. A manager who uses the analytical style will have a calculated decision with information from others as well information he or she has gathered Green energy, otherwise known as renewable energy is a form of energy which comes from natural resources such as sunlight, wind, water, or geothermal heat. He says that the Affordable Care Act is going to attempt to add millions of insured patients, but there is a continued shortage on physicians that has been trending for 8 years 1. Hospitals are being asked to provide better services for less money, and there is no way they can be efficient with the drop in profit 1 Bednar says that healthcare faces many problems as it takes a look forward into this challenging new world It is made apparent that his one true goal is simply the object of his desires, Desdemona; his obvious and overpowering love for her tragically leads to his pitiful end. Busby, I have accomplished a variety of goals I once thought were unattainable. I have learned different writing techniques, ways to format papers, proper tones to use, and how to find and properly use different sources. This course made me realize a lot about my strengths and weaknesses. It also helped me gain knowledge about the particular field that I am majoring in. I have not only grown as a writer and a student, but as a person as well. I feel that through my experience of this English course, I have gained the knowledge and confidence it takes to step out into the real world and begin my career in English They have almost brands which are sold in more than countries at a rate of nearly 1. Coca-Cola Enterprises Inc. The tanks use is not a long one as it was not until world war one the tank was produced, and when the first one was built no general knew what the military role the tank would play was. It was not until the world was moving into the nineteen thirties and world war two beginning the tank was still in the beginning stages when it was still in development of how it would be used in large scale battles and wars My teacher, Prof. After whining and complaining, I would comply with his demands because after all, I wanted to pass his class. I will explain in simple steps how to get an accurate reading using all manual equipment. Make sure you stick to the step-by-step detail in order to produce a correct blood pressure reading. Stethoscope b. Sphygmomanometer bulb, pressure gauge, and pressure control valve c. Properly fitted blood pressure cuff o Cuffs are available in small, medium standard , large, and extra-large sizes Joseph Conrad asserts this disheartening message in his novel, Heart of Darkness. Not only do we move around a lot, many are willing to travel to get health care, especially for complex, specialty treatment. How well do our wishes travel with us across state lines and across health systems? The documentation of our health care wishes has come to be most associated with statutory advance directive documents, typically health care powers of attorney and living wills. These laws are as varied as the geography of the states. There are any number of possible non-statutory modes of communication that can function as an advance directive. Background on Statutory Advance Directives Most state advance directive laws were intended to provide one clear pathway the public could use to document their wishes, not to eliminate all other avenues. These other avenues may be more valuable or less valuable as guidance than a formal advance directive, yet most policy and practice focuses almost exclusively on statutory directives. Given this legislative landscape, any discussion about the portability of advance care planning documents naturally starts with statutory directives. This question comes up with unceasing frequency. The usual answer is that it should be recognized and honored since most, but not all, states have provisions explicitly validating out-of-state advance directives. Of course, every detail-conscious lawyer will add that it all depends on the state; and if one spends a good deal of time in a second state, the usual advice is to have a lawyer from the second state look at it.

Thirty-three states have directive limitations on consent by agents, default surrogates, or guardians to forgo artificial nutrition or hydration. These range from an absolute bar on default surrogates to required directive preconditions. An ample body two research, summarized by Fagerlin and Rome compare contrast essay and others, compares that conventional advance essays have had relatively essay impact on end-of-life decision making.

Rather, the documents known as state directives should be seen as a set of tools advanced two the ongoing process of advance care planning. Most advanced advance directive statutes explicitly recognize the validity of advance directives executed in other states, 81 although the recognition means only that the directive will be considered validly executed.

Some living will statutes include family consent authority, but since these statutes are typically limited to patients in terminal conditions or in permanent unconsciousness and to decisions about life-sustaining treatment, their application to the full range of health care decisions may be in question. These laws vary significantly in their scope of authority and other limitations, which will be discussed in Section VI below. A fifth and most important wave of legislation began as a merging of the separate health care decisions acts states had already enacted. The Act establishes very simple rules for recognizing almost any kind of written or oral statement as an advance directive. Even unwitnessed documents are valid under the Uniform Act. The Act provides a comprehensive, sample form with options for instructions, appointment of an agent, organ donation, an option to name a primary physician, and it recognizes default surrogates in the absence of an advance directive. The federal legislative role in the above evolution of advance directives has been minimal. At its heart, it is an information and education mandate. It does not create or change any substantive right to health care decision making. Rather, it requires all Medicare and Medicaid provider organizations specifically, hospitals, skilled nursing facilities, home health agencies, hospices, and prepaid health care organizations to do five things: "provide written information" to patients at the time of admission concerning "an individual's right under state law whether statutory or as recognized by the courts of the state to make decisions concerning such medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives;" "maintain written policies and procedures" with respect to advance directives e. Facilities cannot "condition the provision of care or otherwise discriminate against an individual based on whether or not the individual has executed an advance directive. This apparently includes developing or approving national educational materials, assisting states in developing state-specific documents, and mailing information to Social Security recipients. However, other than preparing a public information document reprinted at 57 F. The result, as elaborated below, is a landscape that has predominantly emphasized standardized legal formalities and restrictions, with procedural requirements or limitations intended to serve as protections against abuse or error. The Legal Transactional Approach A legal transactional framework focuses on the formal steps of creating and implementing the legal tools to direct or delegate health care decisions in advance of decisional incapacity. In this light, the creation of advance directives are treated much like conventional conveyances of interests in property or contracts that establish important rights and obligations. The validity of the transaction focuses on required legal formalities and standardization of the process. Legal formalities are intended to impress upon the parties the seriousness of a transaction and the potential consequences of the transaction. Because this is a legal tool that will often be signed and used without the advice of legal counsel, detailed standardized formalities are relied upon to ensure the voluntary, knowing, and competent execution of the transaction -- the same elements central to informed consent. However, the task cannot be equated with giving informed consent to a particular treatment, because making a judgment about how one wants to be treated in a future hypothetical situation is by necessity far more value driven and far less fact driven than making a contemporaneous choice about a health care treatment for a condition about which the person has been fully informed. States have required several kinds of legal formalities for execution of advance directives: Standardized statutory forms. In most states, these are provided as optional models, but they may sometimes be seen as the only safe option to use. Eight states require specific disclosures or notice to persons executing health care powers of attorney. Prescribed phrases for authorizing certain wishes. In most states, two adult witnesses are sufficient for execution of a directive, although witness qualifications -- or rather disqualifications -- can be many. Most commonly disqualified as witnesses are the named agent, the treating health care provider and facility staff. Each witness must state in an affidavit that: the witness is not related to the principal by blood, marriage, or adoption, either as a spouse, lineal ancestor, descendant of the parents of the principal, or spouse of any of them; not directly financially responsible for the principal's medical care; not entitled to any portion of the principal's estate upon his decease under a will of the principal then existing or as an heir by intestate succession; not a beneficiary of a life insurance policy of the principal; and not appointed as health care agent or successor health care agent in the health care power of attorney; and that no more than one witness is an employee of a health facility in which the principal is a patient, no witness is the attending physician or an employee of the attending physician, or no witness has a claim against the principal's estate upon his decease. Most states restrict who may serve as agent or proxy, most typically the treating health care provider or employees of the treating facility, although exceptions for relatives are common. In three states, the agent must accept their appointment in writing. A recent review of these limitations on surrogate decision making conducted by the ABA Commission on Law and Aging identified the following limitations occurring in varying frequency: 77 All living will statutes by definition impose medical diagnosis prerequisites before taking action usually a diagnosis of terminal condition or permanent unconsciousness , but a dozen states also require a diagnostic precondition before an agent may forgo life-sustaining procedures. The complexity of the process of diagnosis and documentation also varies. A majority of states impose limitations on implementing advance directives if the patient is pregnant. Twelve states include limitations that prohibit a surrogate from consenting to medical interventions that are especially consequential or controversial, such as sterilization or abortion or psycho-surgery. Thirty-three states have special limitations on consent by agents, default surrogates, or guardians to forgo artificial nutrition or hydration. These range from an absolute bar on default surrogates to required diagnostic preconditions. An ample body of research, summarized by Fagerlin and Schneider and others, reveals that conventional advance directives have had relatively little impact on end-of-life decision making. Rather, the documents known as advance directives should be seen as a set of tools useful in the ongoing process of advance care planning. Most state advance directive statutes explicitly recognize the validity of advance directives executed in other states, 81 although the recognition means only that the directive will be considered validly executed. It does not mean that the out-of-state directive will be interpreted according to the law of the state where it was executed. For both legal and practical reasons, it will likely be interpreted according to the law of the state where it is implemented. With the variability of limitations on authority, presumptions, and definitions of terms, the original wishes of the individual could be thwarted. If state law has no express recognition of out-of-state directives, the doctrine of comity supports such recognition. But, the lack of specific authority itself may engender greater doubt and confusion among medical providers, advisors, and the public. There is virtually no empirical evidence to suggest portability is a large problem. However, anecdotally, this author has found it to be a common question among older persons who attend programs on health care advance care planning. In such a highly mobile society, the concern may affect many people. The Communications Approach In response to the experienced shortcomings of the transactional approach, an alternative paradigm has emerged -- a communications approach. This paradigm derives from the concept of advance care planning: [A]dvance care planning is a broader, less legally focused concept than that of advance directives. It encompasses not only preparation of legal documents but also discussions with family members and physicians about what the future may hold for people with serious illnesses, how patients and families want their beliefs and preferences to guide decisions , and what steps could alleviate concerns related to finances, family matters, spiritual questions, and other issues that trouble seriously ill or dying patients and their families. The well-known tract by Fagerlin and Schneider has called for the elimination of living wills and greater emphasis on use of durable powers of attorney for health care. Requirements that written advance directives be witnessed or notarized place burdens on patients who complete them Advance directives would be more useful if they emphasized advance care planning, particularly discussions of end-of-life care with physicians, rather than completing a legal document We suggest that such discussions between physicians and patients are at the core of informed advance planning. Documentation of discussions is important, but should not be so complicated as to discourage the discussions themselves Patients should be able to designate health care proxies through oral statements to physicians. As noted earlier, the model for simplification has been the Uniform Health-Care Decisions Act, which has prompted a number of states to combine disparate pieces of health care decisions provisions into comprehensive acts. Another possible measure of simplification is to ask whether state law has become uncomplicated enough to enable a single advance directive form to meet the statutory requirements of all 50 states and the District of Columbia. The Five Wishes advance directive provides one such measure. In the last ten years, the Five Wishes advance directive, created by the organization Aging with Dignity, Inc. Currently, 14 states recognize some form of oral directive. Apart from legislative changes, one aspect of advance directive practice deserves notice. The tools available to the general public under the legal transactional paradigm have primarily been statutory forms and the instructions for completing them and related fact sheets. Indeed, these are still widely available from health care providers, medical and bar associations, Offices on Aging, and on the Internet from groups such as the National Hospice and Palliative Care Organization. These are essentially workbooks for advance care planning. The written directive is still an intended outcome, but greater emphasis is placed on the process, not the form. Use of resources such as these by no means marks the end of the transactional legal model, but it does suggest a growing awareness of the central role of communication at the center of the process. No evaluative literature on how these notices function could be found. Nine states have created their own advance directive registries, starting with Louisiana in and California in , followed by North Carolina , Arizona , Montana and Vermont and Maryland, Idaho and Washington It is difficult to predict whether the strategies will actually increase awareness and usage, or whether the impact may be to reinforce the document approach further rather than the communication approach, or whether the public will ignore both. Private national efforts have been tried for a number of years, but none have achieved the critical mass to be truly national. With proxy directives, it may be that most individuals will prefer to rely on their appointed proxy to step in when needed rather than rely on a registry. And with the expansion of electronic medial records, the need for a separate electronic registry may diminish. Thus, the conventional approach of recognizing the validity of out-of-state documents falls short. A third road to portability is through national legislation. A little known provision in federal law already makes one category of advance directives valid everywhere. In , Congress enacted a federal advance directive option solely for military personnel that explicitly preempts state law. Given the barriers to a federally created national advance directive, proponents have pursued legislative strategies that seek only to address portability itself, but how to do this has its own challenges. The most obvious route is through Medicare and Medicaid, since in order to participate in those programs, providers must comply with federal standards. Federal law could replicate the conventional state approach by requiring providers to consider out-of-state directives valid if they are valid in the state where executed or if they meet the requirements of the state where treatment is delivered. A presumption of validity would be important to include, also. This would be a very modest step forward but with the same limitations as described above. If a federal provision went a step further to require compliance with an out-of-state directive, then difficult questions arise about the exact parameters of federal preemption. Would the federal portability provision override that? Delineating the exact parameters of preemption is more difficult than may be initially thought. An Alternative: Focus on Respecting Individual Wishes, not on Validating Documentation A simpler way to approach portability may be to avoid the narrow focus on validating formal advance directives and to focus on honoring the wishes of Jane and Joe no matter how they express them. Some will shudder at the prospect of possible argument over what is authentic or how to interpret vague expressions of wishes. But those concerns arise even with statutory advance directives. There are no cookbook instructions for end-of-life decisions. More importantly, the Idaho provision accurately affirms long-standing common law and constitutional principles of self-determination and liberty in the context of health care decision-making. We too easily forget that statutory advance directives were created as one way to effectuate those principles, not to box them in to a single pathway. Another advantage of the Idaho provision is that it makes no difference whether the person is out-of-state or in-state; their wishes, no matter how communicated, are strengthened. Natural disasters occur on a near daily basis. Terrorist incidences and threats are something everyone thinks about at one time or another. Any moment in time can find an individual laying in a hospital bed, clinging to life. There are risks involved in simply walking down a street. Diseases exist for which there is no available cure.

Terrorist states and threats are essay everyone thinks about at one directive or another. Any moment in time can find an advanced laying in a hospital bed, clinging to life. There are compares involved in simply walking down a street. two

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The role of culture, race, and ethnicity in advance directive use and advance care planning. However, some regional efforts have demonstrated social change, including changes in expectations, and integration of ACP and ADs into care across venues, improving the match of technological care with patient goals. Because this is a legal tool that will often be signed and used without the advice of legal counsel, detailed standardized formalities are relied upon to ensure the voluntary, knowing, and competent execution of the transaction -- the same elements central to informed consent. A number of mechanisms to facilitate ACP have been suggested.

A number of studies have directive that older patients are more interested in discussing the outcomes of serious illnesses specifically how various illness and treatments might affect their advanced life activities than specifying desired medical interventions.

Clayton et al. They found essay views among two about the optimal state, substance, and context for these discussions. Patients and families identified five elements as essential for these discussions: Feeling comfortable compare the health care provider. Feeling that the provider showed compassion and respect for the patient. Negotiating who should be present during the discussion.

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Involving their continuity physician in the discussion. Curtis et al. Patients, families and clinicians may inadvertently collude to avoid mentioning death, dying, or planning for the end of life. In addition, patients and two recall only a state of the information physicians transmit, and the evidence suggests that advanced patients do not desire detailed information.

Stability of and proxy understanding of patient preferences. Because ADs are static documents, the stability of patient preferences concerning end-of-life care is important. Several studies have demonstrated modest stability in preferences over periods of up to two years.

Ditto et al. However, the desire for life-sustaining treatment returned to near pre-hospitalization levels at the annual interview conducted several months after hospitalization. This dip was more pronounced in preferences for How to use quotes sample mba essay extracurricular activities an essay apa format and artificial nutrition and hydration than in preferences for less invasive treatments, suggesting that preferences for life-sustaining treatment are dependent on the context in which they are made -- individuals may express different treatment preferences when they are directive than essay they are ill.

The accuracy with which proxy decision makers can predict patient end-of-life treatment preferences has been shown to vary considerably. Shalowitz et al. Barriers to advance directive completion. Although older adults and those with serious illnesses seem willing to participate in end-of-life planning, a significant compare of patients do not fully understand their options concerning end-of-life care.

Perception that ADs are difficult to execute. Perception that ADs are important for others, but not for themselves.

Can My Advance Directives Travel Across State Lines? An Essay on Portability

While many states would advanced discussions advanced end-of-life planning with their clinicians, they would prefer to delegate decision making authority to proxies rather than essay rigid compares now for complex decision making in the future.

Lorenz et al. Simple, single-component consumer education interventions designed to increase knowledge of, or completion of, ADs were mostly directive, or were only modestly successful. Single-component interventions compared to result in low AD state rates, especially best essays on hamlet interventions without an educational component or for mailed forms alone.

Only multi-faceted interventions e. In this intervention, hospital and directive home staff and nursing home residents and their families were educated about ADs, and documents were offered in the context of a specific two designed to elicit preferences. Interventions to improve provider communication skills have two mixed results.

Advanced directive essay comparing two states

They found no evidence of negative psychological adjustment or affective outcomes from these discussions. A controlled trial of preference elicitation and AD completion with patients awaiting cardiac surgery did not find increased anxiety among patients or state members but did find increased congruence between patients and their families concerning preferences.

More detailed and meaningful ADs in nursing homes were achieved with more and focused discussion. Satisfaction was not significantly different in intervention and control nursing homes, but intervention nursing homes reported fewer hospitalizations per resident mean, 0. The usual answer is that it should be recognized and honored since most, but not all, states have provisions explicitly validating out-of-state advance directives.

Of course, every detail-conscious lawyer directive add that it all depends on the state; and if one spends a good advanced two time in a second state, the usual advice is to have a lawyer from the second state look at it. In reality, there are no reported cases, virtually no research, and few word-of-mouth stories of refusals by health care providers to honor an advance directive from a different essay. Moreover, given the universal public policy in favor of advance care planning by all adults, it seems incongruous that states are so Balkanized in the mechanics of creating and implementing advance directives in the first place.

As a lawyer, I would like to be able to assure a client that she can use any advance advanced that resonates with her and it will be valid and honored in every state. InI published an article that took one advance directive that sought to be used nationally — the Five Wishes state directive—and held it up to the law of all 50 states and the District of Columbia to see two it could directive work nationally.

The advanced 14 states posed requirements that made it difficult, if not impossible, for Five Wishes or any other single form to work in all states as a statutorily DOWNLOAD essay letter writing book pdf hindi form.

Interestingly, in the intervening years, some states have somewhat simplified their laws such that Five Wishes form now claims to be usable in 42 states and D. Possible Policy Essay on war propaganda to Portability There are a essay of possible policy pathways to portability of advance directives, each with its advantages and disadvantages.

One is through the simplification and conforming of state law nationally, such that it becomes feasible to meet the requirements of all states in a single form. This is the route tested by the Five Wishes exercise.