Ethical Problems with Advance Directives During Emergency Visits

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Introduction

Advance Directives are legal documents that outline an individual's preferences regarding major medical decisions.
In Emergency Situations, Ethical Problems arise when advance directives are not available, misinterpreted, or conflict with the wishes of Surrogates or Family Members.
Barriers to the proper management of advance directives in emergency departments include confusion about the documents, their availability, and their accuracy.
Ethical principles such as Autonomy and Fidelity to the patient are central to the use of advance directives, but these principles can be challenged in emergency settings.
Physicians must assess the patient's Decision-Making Capacity, ascertain the existence and accuracy of advance directives, and document conversations about the patient's goals and preferences.

Confusion: Emergency staff may be unclear about the content and validity of advance directives.
Availability: Advance directives may not be readily accessible during emergencies.
Accuracy: There can be discrepancies between the advance directive and the patient's current wishes or clinical situation.
Family Conflicts: Family members may disagree with the instructions in the advance directive.
Documentation: Incomplete or outdated advance directives can lead to ethical dilemmas.

Assess Decision-Making Capacity: Determine if the patient can make their own medical decisions.
Ascertain Advance Directives: Check if the patient has an advance directive and if it reflects their current wishes.
Identify Surrogates: Determine if the patient has named a Healthcare Proxy.
Document Conversations: Record the patient's goals and preferences in the medical record.
Seek Ethics Committee: Consult with an ethics committee when conflicts arise.

Clarity vs. Confusion: Advance directives can sometimes create more confusion than clarity about a patient's wishes.
True Desires: Questions about whether advance directives always reflect the true desires of the patient.
Family Wishes: Conflicts between the advance directive and the wishes of the patient's family.
Clinical Effectiveness: Debate over the clinical effectiveness of advance directives in guiding care.
Technological Advances: Changes in medical technology can render advance directives outdated.

Living Will: Specifies treatments to be given or withheld under certain circumstances.
Durable Power of Attorney for Healthcare: Designates a proxy to make healthcare decisions if the patient is incapacitated.
Medical Living Will: Another term for a living will.
Healthcare Power of Attorney: Another term for a durable power of attorney for healthcare.
Declaration for Mental Health Treatment: Specifies future mental health services.

Binding Nature: States vary in how binding they consider living wills.
Hospital Protocols: Hospitals typically ask for a living will upon admission.
Copies: Creating multiple copies of a living will can help ensure it is found when needed.
Family Wishes: Providers may follow family wishes if no advance directive is available.
Court-Appointed Guardians: Decisions of court-appointed guardians are followed if present.

Availability: Surrogates must be available to make decisions over extended periods.
Knowledge: Surrogates may not know the patient's wishes well enough.
Values Conflict: Surrogates may have different values than the patient.
Ulterior Motives: Surrogates may have ulterior motives, such as financial gain.
Family Disagreements: Conflicts can arise among family members about the patient's care.