Sources of Concern about the Patient Self-Determination Act

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