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Promoting Public Awareness of Advanced Directives
by: Neosha McLaughlin, Rebecca Starr and Kayci Tiner


Introduction
In 1991, The Patient Self-Determination Act (PSDA) required all health care institutions receiving Medicare and Medicaid funds, to inform patients of their right, under state law, to refuse medical treatment and their right to initiate written advance directives. An advance directive is a legal document that either appoints a person to make health care decisions for you in the event you are unable to do so, or specifies in a written document what health care measures you would or would not consent to if incapacitated. This law was enacted to help preserve the autonomy and civil rights of the elderly in guiding their own health care, even if they are unable to articulate preferences. As a result, raising patient's awareness of their decision-making options for future health care, along with encouraging patients to complete an advance directive has become an important part of social work intervention.

Statement of Need
From our research and interviews, we found that making an advance directive for health care has many benefits, such as helping individuals and their families think about future health care treatment, enhancing self-determination, fostering better communication between patients and family, and relieving families of the burden of traumatic decision making.

While advance directive information can be found anywhere from the doctor's office to the World Wide Web (www.forrestgeneral.com/advance7.htm), most people find out about advance directives upon admission to the hospital. As we have learned from both our research and interviews, completion rates of advance directives are poor in stressful situations—for example, a hospital admission. We researched several studies that found completion rates increase when introduced in a non-stressful environment—for example, at a routine doctor exam. Interviews with hospital administrators and social workers have confirmed that completing an advance directive in a hospital setting is not ideal since it can add to the patient's anxiety and nervousness. Nonetheless, both administrators and social workers are legally required to provide such information and education to patients.

During the course of our research, we found that there are other reasons why people do not have an advance directive or do not wish to initiate one. An article found in Research on Social Work Practices (Gockel, 1998), stated several reasons why advance directive completion rates are poor. These reasons include procrastination, possible family upset, and need for assistance with the forms. A hospital social worker added other variables such as cultural beliefs, and socioeconomic status and educational level. From our interviews we learned physician involvement is a key factor in completion rates of advance directives; however we have found that most physicians do not take an active role in promoting advance directives.

Description of the Intervention
Since providing advance directive information has become an important area of social work intervention, we decided to educate future social workers about advance directives for our first semester Community Project presentation. The second semester of our project was devoted to working on our original goal, which was to promote public awareness of advance directives. First, we brainstormed ideas of where to hold our intervention and what type of format we should use to provide our information. Then, we divided the task of calling places to find out the possibility of holding our intervention at their site. We contacted the fair grounds, the local mall, the University and a local church. The fair grounds and the University did not have any appropriate activities planned. The church was supportive, but unfortunately all the times they offered conflicted with our personal schedules. The mall seemed disinterested yet allowed us to complete an application and submit a letter on our project. After they processed the application, the mall personnel told us our activity fell under the free speech category and required another proposal as well as money to reserve a booth. This made us feel uncomfortable so we decided to forego the mall, but unfortunately this left us with no place to go.

Evaluation of the Intervention
Part of the reason that our goal was not met for this project was the barriers we faced as a group. We all had different ideas of how to do things. Site location and the topic in general became uncomfortable for some members. We felt disappointed about the outcome of our Community Project. We were, however, able to realize that we had a part in educating future social workers about advance directives, and this was a first step in increasing public awareness.

Reflections on the Project
Start your planning early! Since we did not start our planning early we encountered a great deal of scheduling conflicts that led to missed opportunities. If you want to hold an intervention out in the community, we suggest looking into Health Fairs, health care exhibitions at malls and community centers, and local area agencies on aging for upcoming health care events. Another thing to consider is the controversial nature of this topic and what the free speech guidelines related to it are. Also, if you think you might encounter certain costs, such as photocopies and handouts, research the availability of state and federal grants for this type of intervention at www.ed.gov/funding.html. Above all, we suggest planning an intervention in a non-stressful environment in order to enhance interest and increase advance directive completion rates.

References
Bailly, D. & DePoy, E. (1995). Older People's Responses To Education About Advance Directives. Health and Social Work. 53(3). 223-232.

Gockel, J. & et al. (1998). Advance directives: A Social Work Initiative to Increase Participation. Research on Social Work Practice. 8(5), 520-528.

High, D. (1994). Families' Roles In Advance Directives. Hastings Center Report. 24 (6). 216-219.

Hoffman, D.E. & et al. (1996). The Dangers of Directives or the False Security of Forms. Journal of Law, Medicine & Ethics. 24(1), 5-17.

Katz, Rosamond & Roth, Anita & Winslow, Craig. Health Hippo: Advance Directives. Patient Self-Determination Act: Providers Offer Information on Advance Directives but Effectiveness Uncertain. Retrieved September 10, 1998 from the World Wide Web: ( http://frwebgate.access.gpo.gov/cgibin/getdoc.cgi?dbname=gao&docid=f:he95135.txt).

Mezey, M., Mitty, E., Ramsey, G., (1994). Making The PSDA Work For The Elderly. Generations. 18 (4), p13-23.

Osman, Hana & Perlin, Terry M. (1994). Patient Self-Determination and the Artificial Prolongation of Life. Health & Social Work. 19(4), 245-258.

Pellegrino, E.D. (1992). Ethics. Journal of American Medical Association. 268 (3), 354-355.

Peppin, J.F. (1995). Physician Neutrality and Patient Autonomy in Advance Directive Decisions. Issues in Law and Medicine. 11, 13-20.

Phillips, M. & Sansone, P. (1995). Advance Directives For Elderly People: Worthwhile Cause or Wasted Effort? Social Work. 40 (3), 397-407.

Pugh, Donna & West, Daniel J. (1995). Advance Directives and the Self-Determination Act: A Patient's Perspective. Omega: Journal of Death & Dying. 30(4), 249-256.

Robertson, George S. (1995). Making An Advance Directive. British Medical Journal. 310(6974), 236-238.

Rubin, Susan M. & Strull, William, Michael F. & Weiss, Sarah J. & Lo, Bernard (1994). Increasing the Completion of the Durable Power of Attorney for Health Care. JAMA: Journal of the American Medical Association. 271(3), 209-212.

Sherman, F., Torroella, M. & et al. (1997). Advance Directives: When, Why, And How To Start Talking. Geriatrics. 52(4) 65-71.

The Quarterly Newsletter of the Robert Wood Johnson Foundation. (1997). Shortcomings of Advance Directives. (Advances No.3). Retrieved September 29, 1998 from the World Wide Web: www.rwjf.org/library/93-3-10.htm.

Interviews

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