Problems with advance refusals
Winter and Cohen in their article 'ABC of intensive care - Withdrawal of Treatment' (BMJ 319 306-308) recognise one of the problems with advance directives when they correctly state 'The advance refusal of treatment is legally binding provided certain conditions are met. ... A problem still exists unless they are precisely worded.'
The introduction to their coverage of advance directives ('When to withdraw treatment') perhaps targets why traditional advance directives are less and less useful when they say 'These decisions remain difficult because of the paucity of data on different clinical scenarios.'
When advance directives were first introduced, the application of standard 'heroic measures', often without reasonable expectation of result, was far more common than it is today. In that situation, a general advance directive about refusing, say, CPR, was an appropriate statement of common sense. The situations facing modern intensive care units are far more complex. The tendency towards 'precise wording' in advance directives to make them legally binding has difficulty keeping up with the pace of medical technology.
An alternative approach that is finding increasing favour, either as an adjunct to the advance directive or as a stand-alone instrument, is the 'values history.' Values histories relate to the declarant’s values rather than instructions. The expression of a patient’s values are provided as a basis on which medical treatment decisions can be based (rather than including explicit instructions on specific treatments). They identify core values and beliefs in the context of terminal care that are important to the patient. Values histories take a goal-based rather than prescriptive approach, giving guidance on a policy to be implemented rather than the medical means to the end. The legal persuasiveness of them is less strong, but they may be useful adjuncts when a person is seeking to have an advance refusal respected, or they may provide valuable guidance in their own right.
I would suggest that, in general, the trend towards greater use of values in advance statements is more valuable to patients and intensive care doctors than is the trend towards increasingly specific wording of treatments to be refused, and that the former trend is to be encouraged.
Further details on values histories may be obtained from the Living Will and Values History Project, BM 718, London WC1N 3XX.
M.Phil, Law & Ethics in Medicine
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