Sources of Concern About the Patient Self-Determination Act

Abstract

Advance directives have provoked a number of reservations. As the PSDA [Patient Self-Determination Act] goes into effect, requiring discussion and implementation of directives, it will be essential to address physicians' further reservations as they arise. Yet that necessary step will not be sufficient to ensure that the PSDA produces more benefit than harm. There is a risk that written advance directives may wrongly come to be viewed as the only way to make treatment decisions for the future. Physicians and other care givers may improperly begin to require an advance directive before treatment may be forgone for incompetent patients. To avoid this, staff education must include discussion of the various ways to decide about life-sustaining treatment and plan future care. Even under the PSDA, not all patients will use advance directives. There is a further risk of confusion about the procedures and materials to use in implementing the PSDA. All personnel in the relevant institutions will need clarification of the step-by-step process to be followed with patients, the written materials to use, and how to resolve specific questions. The information conveyed to patients must be understandable, accurate in summarizing the patient's rights, and sensitively communicated. All staff members who are involved must be trained. Institutions must design appropriate protocols. Finally, there is a risk that the PSDA will reduce the discussion of treatment options and directives to a bureaucratic process dominated by brochures and forms. To avoid this, the discussion of advance directives must be part of an ongoing dialogue between physician and patient about the patient's health status and future....