Academic journal article Health and Social Work

Older People's Responses to Education about Advance Directives

Academic journal article Health and Social Work

Older People's Responses to Education about Advance Directives

Article excerpt

Because advancements in medical technology have increased the life span, the debate regarding the quality of life during those additional years continues to be a major concern to social workers. An area of increasing attention is autonomy, particularly in light of the growing body of research that shows a positive relationship between the capacity to make autonomous decisions and well-being in later life (Collopy, 1990; Rodin, 1986). Intersecting both autonomy and technology is advance directives, which allow individuals to express preferences for life-sustaining treatment when they are able and to retain autonomy over their medical treatment and ultimate right to die should they become decisionally incapacitated. However, even with the trend toward autonomy over one's life course and legislation requiring certain providers to inform health care consumers about their legal choices, advance directives are infrequently used (Emanuel & Emanuel, 1989; Nicholson & Matross, 1989).


Since the passage of the Patient Self-Determination Act of 1990 (P.L. 101-508), Medicare and Medicaid providers such as skilled nursing facilities and hospitals are mandated not only to inform clients and patients about their rights to make health care decisions (that is, the rights to refuse treatment and execute advance directives) but also to maintain written policies about the implementation of those rights. This legislation recognizes and supports individual choice of health care intervention, legitimizing the right of people to exercise their autonomy. In other words, advance directives can empower people by ensuring personal autonomy beyond situations in which it can be directly actualized (Galambos, 1989).

The notion of indirect autonomy has been supported in the literature on adult development. Differing with previous conceptualizations of autonomy, Collopy (1990) and Agich (1990) have suggested that as one ages, the definition of autonomy shifts from the capacity to directly act on decisions to the capacity to have decisions implemented. This qualitative change in meaning is a response to the human condition of dependence resulting from loss of health or function in old age, which Agich (1990) suggested should not necessarily interfere with one's right to exercise autonomous decision making.

Despite research supporting a positive relationship between autonomy and well-being, the legislated mandate to distribute materials informing individuals of their right to advance directives, and the growing evidence that health care recipients want discussions about options (Lo, McLeod, & Saika, 1986; Saultz, 1990), these discussions are infrequent, particularly between physicians and patients. Yet because so many elderly people seek treatment in physicians' offices (a location not covered in the Patient Self-Determination Act), this location would be ideal for educating elderly individuals about their future health care options.

Because the mission of the medical profession is to save lives and because physicians receive limited skills training for counseling in medical school, many physicians experience discomfort introducing advance directives to their patients (Saultz, 1990). However, Galambos (1989) suggested that elderly people who are educated about their options may not choose a formal means to convey their wishes. High (1988) and Kapp (1989) posited that this hesitance may result from the strong preferences and expectations that elderly people have for family involvement in health care decision making. The decision to delegate decision-making responsibilities to others must be recognized and respected as one way in which elderly people attempt to retain control over their lives (Kapp, 1989). Unfortunately, delegation of health care decisions to family members is often not accompanied by detailed and clear discussions of future wishes, leaving the family to guess about health care preferences (High, 1987; Jecker, 1990; Zweibel & Cassel, 1989). …

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