The failed Patient Self-Determination Act and policy alternatives for the right to die

The empirical evidence regarding the implementation and impact of the federal Patient Self-Determination Act is examined in this article. The Act was designed to increase the use of advance medical directives in light of the U.S. Supreme Court's Cruzan decision. Research shows that the law has had little effect and that the use of advance directives has scant relation to medical treatment and care. Various policy alternatives for the right to die are also examined. The authors conclude with an analysis of the likely impact of medical costs, fruitless treatment, and rationed health care on limiting life-prolonging treatment.     

The Failed Patient Self-Determination Act and Policy Alternatives for the Right to Die

ABSTRACT

The empirical evidence regarding the implementation and impact of the federal Patient Self-Determination Act is examined in this article. The Act was designed to increase the use of advance medical directives in light of the U.S. Supreme Court's Cruzan decision. Research shows that the law has had little effect and that the use of advance directives has scant relation to medical treatment and care. Various policy alternatives for the right to die are also examined. The authors conclude with an analysis of the likely impact of medical costs, fruitless treatment, and rationed health care on limiting life-prolonging treatment.     

Behavioral economics of death and dying decisions: Both rational and irrational approaches

A decision to accept death and forego life-extending medical procedures can be both rational and irrational. This article reviews perspectives on death from the viewpoint of behavioral economics, which relies on psychology as the basis of decision-making in this regard. According to behavioral economics, both the benefits of living and the costs of death should be emphasized so that a person who is thinking about suicide reconsiders that option and, hopefully, changes his or her mind and tries to safeguard life and avoid life-threatening risks. One way to make dying decisions more rational is to write out a living will or advance directives to help doctors understand a patients’ intentions with regard to decisions about dying should they become unable to articulate that intention at some later, critical, life-or-death situation. Living wills and advance directives can therefore reduce the chances of mercy killing or euthanasia, especially in the context of a developing country, especially when life-extending technologies are limited.     

A Heavenly Collaboration: Social Workers and Churches Working to Increase Advance Directive Completion among African American Elderly

The Patient Self-Determination Act (PSDA) was enacted in 1990 as a guarantee to patients that their wishes surrounding end-of-life care would be honored if they expressed verbally or through advance directives the desired level of care they wished to receive at the end of life. Research shows that African Americans have the lowest percentage of advance directives completed among the major racial groups in the United States despite the PSDA's purpose. African American elderly rely on community supports such as social workers and the church to meet physical and spiritual needs. However, these two entities have yet to collaborate to eradicate the dismal percentages of completed advance directives among African American elderly. This article explores how the religious community and social workers can work toward educating this population on the importance of advance directives and empowering them to take the necessary steps at completion if they choose to do so.     

Walking a Tightrope: Case Management Services and Outpatient Commitment

Effective case managers in community mental health are successful at forging a working alliance with recipients. This article explores one key aspect of case management practice, serving involuntary clients, specifically those on outpatient commitment orders. In 19 intensive interviews, a subset of a larger study, case managers shared their perceptions of the utility of outpatient commitment with a focus on how such orders impacted the professional relationship. We argue that the use of advance psychiatric directives and shared decision-making processes can reduce the need for coercive practice.     

An Analysis of the Patient Self-Determination Act of 1990

Advance directives (ADs) provide a way to express medical care preferences at the end of life, yet they are underutilized. This article analyzes the effect of the Patient Self-Determination Act and presents recommendations for the improvement of AD legislation. Although the Patient Self-Determination Act was intended to educate patients, clinicians, and the public about ADs, more work is needed to improve involvement in end-of-life care decision making for individuals who may be disenfranchised in this process.     

Be gentle about death ... and leave the balcony open

This meditation on advance directives shows how such documents are part of a larger social movement. People are now reclaiming the right to direct their own dying, a process that requires the active support of the community around them.     

Don't be cheeky': Requests, directives and being a child

The study described in this article collected naturalistic data from six children aged eight to nine talking with their relatives and friends. The article focuses on directives and requests used by the children and their interlocutors in informal conversations. It proposes that – as previous research has found – some requests and directives are distinctive because of the children's social status as children , but also suggests that, since 'being a child' is a relational and socially negotiated role, its significance varies across different interactions.     

When Death Isn't Dead: Implicit Social Rationing during Resuscitative Efforts

In this paper, I address the relationship between social death and clinical-biological death during resuscitative efforts. In Western societies, resuscitative efforts are the medical intervention of choice when sudden death occurs. The widespread use of this technology puts emergency department staff in a difficult gatekeeping position. They are expected to save lives, but, at the same time–when their efforts become futile–to prepare for a dignified death. I show that certain groups of patients are much more likely to be considered socially dead regardless of their clinical viability, while others are less likely to be considered socially dead even when irreversible biological death has set in. The result is an implicit rationing of the lifesaving endeavors based on the social worth of the patient. This rationing annihilates initiatives, such as advance directives, which were instituted to empower patients. Social scientists usually suggest that the solution to the negative effects of rationing is to increase accessibility for all populations; however, resuscitative efforts are a prime example in which less access for all groups–instead of for some–might be preferable. This paper is based on observations of 112 resuscitative efforts during a fourteenth-month period and interviews with 42 health care providers.     

Fighting in the legal grey area: an analysis of the German Federal Court of Justice decision in case preimplantation genetic diagnosis

According to the German Embryo Protection Act, PGD has been banned in Germany since 1990; one reason is the legislature’s avoiding to insert a revision clause regarding medical advance into the law. The ruling of the German Federal Court of Justice of July 2010 shows the problems resulting out of this approach and declares PGD to be permitted in certain cases. The article discusses the necessity for, as well as the problems of, an interdisciplinary dialogue in the field of reproductive medicine.     

Rescaling Gender Relations: The Influence of European Directives on the German Gender Regime

During the 1960s–1990s, a gradual yet definite shift inthe organization of gender politics in the European Union (EU)and member states has become apparent. This shift began withthe implementation of the early gender directives of the 1970sand has since evolved to include a partial "rescaling" of policy-makingfrom national to transnational spaces and a gradual redefinitionof gender regimes and policies at the national level. As a result,gender policy cannot be viewed as either predominantly transnationalor national but arises through interaction of multiple and coexistingpolicy spaces. In this article, I use a multiscalar analysisto highlight this complex interaction. I draw on (West) Germanyas a specific case study to offer a historical analysis of theimplementation of the early European gender directives and themanner in which these developments have contributed to the redirectionof the German gender regime and the emergence of a new "hybridregime."     

Challenging the Authority of the Medical Definition of Disability: an analysis of the resistance to the social constructionist paradigm

This article attempts to explain why the social constructionist paradigm has failed to replace the medical model in American disability theory. The social movement led by American disability activists attempted to reframe the definition of disability using a minority group model based on the social constructionist paradigm. This paper argues that the disability movement was unable to successfully advance the social constructionist paradigm because the activists accepted the Americans With Disabilities Act (1990) despite its ideological basis in the medical model of disability, and the social constructionist theory does not adequately account for the importance of structural constraints to redefinition.     

Recalcitrance,compliance and the presentation of self: Exploring the concept of organisational misbehaviour in an English local authority child protection service

This article examines how social workers reinterpreted certain legal requirements to meet their organisation's performance targets. Using an ethnographic approach, I combine organisational misbehaviour theory and Goffmanesque conceptions of dramaturgy to explore the regional activity of one team in a statutory agency. I argue that singly neither misbehaviour theory nor dramaturgical performances account for our understanding of why workers respond differently to organisational changes in a neo-liberalist environment. This study differs from current literature by shifting emphasis away from workers either resisting or conforming with organisational directives on to the ways in which individuals and collectives devise methods which instead give the appearance of co-operation. I demonstrate how workers disguised their resistance in an attempt to achieve potentially unachievable objectives and in turn avoid disciplinary action. I conclude by suggesting that applying Goffman to studies of organisation can advance scholars' understanding of how certain individuals respond to change and might come to be defined as loyal and compliant. This approach can also encourage discussions relating to the concept of recalcitrance and whether it is developed, and enforced, by those in powerful positions on the basis of their own desire to be well regarded by others.     

Toward a sociology of finitude: life,death, and the question of limits

Progressing beyond the given has been a key modern tendency. Yet modern societies are currently facing the problem of how to put limits on progress, expansion, and growth, live within them, and preserve (rather than transcend) the present. Drawing on economic sociology scholarship on valuation and morality in economic life, this article develops and applies the term economization to analyze the enactment of limits on progress. The question of end-of-life care—when to stop medical efforts to prolong life, postpone death, and advance the scientific frontier—serves as an illustrative empirical case that sheds light on limit-setting in general. My analysis of this case combines historical, ethnographic, and in-depth interview data on US palliative care clinicians, who specialize in making life-and-death decisions in acute care hospitals.

     

Preventing Elder Abuse and Neglect Through Advance Legal Planning

Recent trends in adult protective service literature and legislation reflect a growing interest in advance planning to prevent elder abuse and neglect. This article provides basic planning guidelines and discusses in general terms the most important legal planning documents: the living will, the durable power of attorney for health care, the durable power of attorney, and the last will and testament. It also presents in general terms potential legal, medical, and financial planning tools that may function as alternatives to guardianship. Both the benefits and limitation of these documents and tools are discussed.     

University Students’ Views on the Utility of Psychiatric Advance Directives

Abstract

Objective: Rates of serious mental illnesses (SMIs) among university students are increasing, and universities are struggling with how to respond to students who show SMI symptoms. Psychiatric advance directives (PADs) allow individuals, when well, to document their wishes for treatment during a psychiatric crisis. This project explored the feasibility of using PADs in university settings by examining students’ views towards PADs. Participants: Forty university students with SMIs were recruited for this study from 1 large university. Methods: A mixed-methods design was used, with both quantitative survey instruments and qualitative interviews with students. Results: Respondents were positive about PAD utility for students. Respondents saw PADs as beneficial because PADs gave students control over their treatment. However, students also considered PADs potentially problematic because PAD use raised a risk of breaching student privacy and stigmatizing students with SMIs. Conclusions: Although a promising intervention for students with SMI, this approach requires further research.     

The Termination Stage in Bowen's Family Systems Theory

The termination stage has always been recognized as an important aspect of the clinical intervention process. Careful attention to that stage is even more critical in the current practice environment of short-term intervention and demands for measurable outcomes. Bowen's family systems theory, while well established in the field of clinical practice, does not incorporate clear directives for the practitioner about the ending stage of intervention. Still, its major concepts for assessment and intervention suggest a range of termination activities that can affirm and summarize a family's gains. In this article the authors offer a variety of ending strategies for use within family systems theory.     

Corruption in public procurement and private sector purchasing

Abstract

This article points out similarities and differences between purchasing by the public and private sectors outgoing from concepts of procurement processes and buying centres. It also analyses corruption issues in both sectors' purchasing activities. The focus is on public procurement within the European Union (EU), where member states have to follow the European Community directives for public procurement.     

Negotiated Orders: The Negotiation of Directives in Paramedic-Nurse Interaction

Whereas the “negotiated order approach” emphasizes the importance of communicative events in the constitution of organizational settings, there has been little attempt to formally describe the properties of talk that occur in these settings. This article demonstrates that detailed examination of the temporal unfolding of negotiative processes contributes to our understanding of the bundle of tasks which comprise organizational settings. Through close analysis of the negotiation of directives in paramedic calls for emergency field orders, I demonstrate that negotiation is more than a metaphor for describing organizational order; real-world negotiations are complex interactional processes which can be described in their rich detail.     

Spirit Writing in Vietnam: Political Lessons from the Beyond

Spirit writing is a rare form of trance mediumship in contemporary urban Hanoi and part of the resurgence of popular religious practices in late Socialist Vietnam. This article explores the transmission of otherworldly messages from heroic political and military leaders of the past via an urban female spirit medium and examines practices of translation, decoding and implementing celestial directives. Based on ethnographic fieldwork, the paper investigates how efforts to execute instructions from the beyond are intertwined with mediation, materiality, and technology. Drawing on an analysis of messages from the spirit of H? Chí Minh and other heroes of the past, this paper argues that spirits interfere in Vietnam’s current political matters by questioning issues of injustice and by advising the authorities with regard to ritually safeguarding the country’s borders.