In My Best Interest.
BACKGROUND
Advance directives (ADs) have traditionally been viewed as clear instructions for implementing patient wishes at times of compromised decision-making capacity (DMC). However, whether individuals prefer ADs to be strictly followed or to serve as general guidelines has not been studied. The Veterans Administration's Advance Directive Durable Power of Attorney for Health Care and Living Will (VA AD) provides patients the opportunity to indicate specific treatment preferences and to indicate how strictly the directive is to be followed.


OBJECTIVE
To describe preferences for life-sustaining treatments (LSTs) in various illness conditions as well as instructions for the use of VA ADs.


METHODS
A descriptive study was performed collecting data from all ADs entered into the medical record at 1 VA Medical Center between January and June 2014.


METHODS
Responses to VA AD with emphasis on health care agents (HCAs) and LW responses.


RESULTS
Veterans were more likely to reject LST when death was imminent (74.6%), when in a coma (71.1%), if they had brain damage (70.6%), or were ventilator dependent (70.4%). A majority (67.4%) of veterans preferred the document to be followed generally rather than strictly. Veterans were more likely to want VA ADs to serve as a general guide when a spouse was named HCA.


CONCLUSIONS
Most of the sampled veterans rejected LST except under conditions of permanent disability. A majority intend VA ADs to serve as general guidelines rather than strict, binding instructions. These findings have significant implications for surrogate decision making and the use of ADs more generally.
1 Cleveland Fellowship in Advanced Bioethics, Cleveland, OH, USA.
Patricia A
PA
Mayer
1 Cleveland Fellowship in Advanced Bioethics, Cleveland, OH, USA.
Bryn
B
Esplin
2 Frances Payne Bolton School of Nursing at Case Western Reserve University, Cleveland, OH, USA.|3 Statistics Resource Center, Geriatric Research Education and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA.
Christopher J
CJ
Burant
4 Geriatric Research Education and Clinical Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA.
Brigid M
BM
Wilson
5 Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA.
MaryAnn Lamont
ML
Krall
6 Clinical Ethics, University Hospitals Case Medical Center, Cleveland, OH, USA.|7 School of Nursing and School of Medicine, Case Western Reserve University, Cleveland, OH, USA.
Barbara J
BJ
Daly
5 Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA.|8 Department of Bioethics, School of Medicine, Case Western Reserve University, Cleveland, OH, USA.|9 Clinical Ethics Consultation, Center for Biomedical Ethics, MetroHealth Medical Center, Cleveland, OH, USA.
Jason
J
Gatliff
D000328:Adult; D016223:Advance Directives / Q000706:statistics & numerical data*; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006787:Hospitals, Veterans / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009820:Ohio; D057240:Patient Preference / Q000706:statistics & numerical data; D055815:Young Adult
advance directives; decision making; end-of-life care; heath care power of attorney; living wills; surrogates