The working assumption of these guidelines is that the Patient Self-Determination Act provides a clear framework within which advance directive protocols will be developed by the institutions.

It is also assumed that while institutions may want to review protocols developed brother institutions, they will also want to design a protocol of their own that reflects their particular institutional ethos.

As a result, there is no inclination here to offer the “perfect” protocol. Instead, what is offered as something thought to be more useful, is a set of criteria with which to answer the critical question: What should a good advance directive protocol look like?

Another guiding assumption is that while other institutional protocols (e.g., those for DNR, treatment termination and categories of patient care) are designed to deal directly with the patient’s medical condition, the advance directive protocol has to do primarily with the patient’s medical preferences and values. It could therefore be described as the center piece around which thee other patient care protocols operate.

It is assumed that the success of the advance directive protocol will depend upon the successful development and implementation of programs for the in-service education of professional staff and the continuing education of the community served by the institution. Finally, it is assumed that the successful implementation of the advance directive protocol requires each institution to develop a policy about advance directives that can be set out in the protocol. 


In considering the overriding purpose of the advance directive protocol, the following drafting goals can be considered. The protocol can ensure:

* the autonomy and informed consent of the patient;

* the integrity of the institution’s professional staff, providing them with appropriate immunity when honoring in good faith the terms of an advance directive, and permitting them to withdraw from a particular cases where they have conscientious objections to specific directives;

* the integrity of the institution’s mission to provide appropriate and timely humane medical care;

* the integration of thee three distinct but interdependent sets of interest.


The protocol should cover the following areas, to ensure day-to-day effectiveness:

* the inquiry as to whether the individual has an advance directive and, if so, provision for documentation of the advance directive;

* the placement of the advance directive prominently in the patient’s medical chart;

the continuous tracking (and transfer, when necessary) of the advance directive throughout the patient’s stay in the institution;

* the training of staff to explain the medical, legal and ethical implications of advance directives to patients and to their families;

*effective and timely communication between health care providers and the individual, including his or her family, so that the terms of the advance directive inform all medical decisions as they are made;

* documentation of the wishes of individuals who wish to change, in whole or in part, the terms of their advance directives;

* documentation of the wishes of individuals who wish to rescind their advance directives;

* the resolution (possibly through an ethic committee) of any conflicts that arise between care providers and patients, care providers and family members and among family members;

* guidelines for dealing (possibly through an ethics committee) with cases whereto terms of an advance directive are unclear in themselves, or in relation to the patient’s clinical condition;

an ongoing method of evaluation or assessment to determine where and when the protocol is working and is failing to work;

provision for the possibility that the protocol is not working in whole or in part, and for timely and effective amendments to secure its satisfactory operation.

Substantively, the protocol will need the describe:

the right to refuse medical treatment, including nutrition and hydration,which is protected by the Constitution’s liberty interest clause;

* state law (both legislation and law created by court decision) relating to the formulation and execution of advance directives and the refusal of treatment;

* state law relating to the physician’s and institution’s obligations in the absence of a written advance directive;

* the principle that the provision of that medical care will not be conditioned on whether or not the patient has completed an advance directive.




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