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The battle over Terri Schiavo, a young Florida woman who, in February 1990, experienced cardiac arrest and lapsed into what medical experts have called a "persistent vegetative state," has brought the subject of an advance directive to the nation's attention (Levesque, 2003).


A 1991, Federal Law entitled the "Patient Self-Determination Act," mandated that home care agencies and other healthcare providers must furnish advance directive information to patients at admission. Advance directive is a general term that applies to two types of legal documents.


A living will allows you to state in advance the type of treatment you want or do not want if you ever become mentally or physically unable to choose or communicate your wishes.


A durable power of attorney enables you to authorize another person to make medical decisions on your behalf if you become incapacitated (Angelo, 2002).


Home care clinicians have an opportunity to establish a meaningful dialogue about this important subject; however, simply asking patients if they have an advance directive should only be the first step in helping patients make their wishes known.


For patients who have an advance directive:


* Ask if they have discussed their end-of-life wishes with their family and health provider.


* Identify the patient's designated healthcare surrogate.


* Determine if the surrogate, the primary care provider, and any family members involved in their care have been given copies of the patient's advance directives.



For patients who havenot formulated an advance directive:


Home care admission is an excellent time to begin this process. Patients who may have just experienced hospitalization can be more receptive to discussing end-of-life wishes. Ask the patient, "During your recent hospital stay, who would have been responsible to make decisions for you, had you been unable to communicate?" If the patient cannot answer, it may be the right time to explain the benefit of an advance directive. Unless culturally contraindicated, encourage the patient to make these decisions.


As advocates who engage patients in advance planning, clinicians can begin to understand their patients' views regarding what makes life worth living and their fears about medical intervention and loss of dignity. In addition, an open dialogue can help clarify misunderstandings among patients and their caregivers.


As our patients continue to live longer and medical interventions are able to sustain life, often without regard to the quality of that life, the clinician can educate patients and families regarding the importance that their wishes are known, especially at the end of life.



Advance care planning documents and information can be found at: Project Grace:


American Association of Retired Persons:


Medline Plus Health Information:


Partnership for Caring: America's Voices for the Dying:




Levesque, W. (2003, November 11) Schiavo's wishes recalled in records. St. Petersburg Times (online). Retreived January 14, 2004 from [Context Link]


Angelo, S. (2002) Advance directives . Medline Plus, Medical Encyclopedia. Retreived November 20, 2003 from [Context Link]