Patient Self-Determination and the Artificial Prolongation of Life

By Osman, Hana; Perlin, Terry M. | Health and Social Work, November 1994 | Go to article overview

Patient Self-Determination and the Artificial Prolongation of Life


Osman, Hana, Perlin, Terry M., Health and Social Work


As health care professionals, social workers advocate for comprehensive and thorough care for all patients. What should we do when the patient refuses treatment? when the patient wants less than all we have to offer? As representatives of a health care system designed and dedicated to saving life, how should social workers react to those who wish to forgo life-sustaining treatment?

Ethical, legal, and psychological questions abound when the issue is life itself. The social worker is frequently at the hub of whirling conflicts, seeing the patient losing control, as physicians are intent on their duty to treat and families are torn by their need to protect.

Decisions at the end of life require responses in which factual and emotional issues overlap. What does it mean to disconnect a ventilator that is breathing for a dying or comatose patient? What impact will the cessation of artificial hydration and nutrition have, not only on the patient but also on family, caregivers, and institutions? Does the decision not to place the same patient on life support in the first place make a moral difference? Courts and philosophers have held, almost uniformly, that there is no significant distinction between the two situations. Withholding and withdrawing care, the conventional wisdom states, are morally equivalent. But if you ask nurses, physicians, or social workers if there is any real difference, nearly all will answer with a resounding "yes!" Withholding care, most will state, seems somehow less problematic. In withdrawing care, health care practitioners feel as if they are "killing" the patient. Does having the patient's advance directive render these choices easier?

Society has long been familiar with some of the issues surrounding the artificial prolonging of life, such as malpractice litigation and the excessive expense of new medical technology. Emerging from these conflicts, patient self-determination has recently gained much prominence as a guiding principle. What could be more appropriate or more attuned to social work ethics than to follow the patient's wishes?

Legal instruments that clarify patients' wishes when they become incapable of expressing those wishes have been popularized. Recent federal legislation has encouraged use of these devices, as a group called "advance directives," including living wills and durable powers of attorney for health care. Living wills allow patients to state their preferences regarding the acceptance or refusal of life-sustaining treatments and other medical interventions. Durable powers of attorney for health care are documents designating a surrogate to make health care decisions when the patient becomes incapacitated (Perlin, 1992). Social workers must be familiar with these devices, as they are instruments for advocacy of the patient's wishes.

The clinical implications for social work practice include three areas:

1. involving the patient in health care planning by ensuring that the patient actively participates in the decision-making process (Osman, 1991) and is informed about alternatives

2. advocating for the family's interest

3. serving as a communication conduit between the patient-family unit and the health care institution and working with other health care professionals to ensure that the patient's wishes are carried out.

These goals can be accomplished by creating "a climate in which informed choice and consent are genuine" (Mizrahi, 1992, p. 250) and by ensuring that patients' wishes are accurately expressed in the advance directives.

AUTONOMY AND THE PATIENT SELF-DETERMINATION ACT OF 1990

Patients' right to self-determination has its roots firmly grounded in the concept of individual autonomy. Autonomy refers to self-rule or self-governance (Beauchamp & Childress, 1989). In health care, this concept is applied to competent patients in their consent to or refusal of medical treatment and intervention. …

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