Emanuel L
Division of Medical Ethics, Harvard Medical School, Boston.
J Clin Ethics. 1993 Spring;4(1):8-16.
As a result of the recent intense focus on advance directives, it is now possible to resolve several questions. It is clear that instructional directives are best able to represent a patient's wishes in the clinical context if they make use of scenario- and treatment-specific statements, perhaps combined with other types of value statements. Instructional directives are a type of advisory document that can provide clear and convincing evidence regarding a patient's wishes and, as such, the patient's wishes can thereby be constitutionally protected. It is clear that proxy judgments that are not specifically informed are not a good match with patients' wishes. Proxy decisions should, therefore, be guided by instructional directives--verbal or documented. It is now possible to construct a good clinical process for advance planning that is practical, maximizes benefits and minimizes risks, and includes both instructional planning and proxy empowerment. However, we have a long way to go before advance planning is widely and appropriately practiced.
由于近期对预立医疗指示的高度关注，现在有可能解决几个问题。很明显，如果指导性指示使用针对具体情景和治疗的陈述，或许再结合其他类型的价值陈述，那么在临床环境中它们最能体现患者的意愿。指导性指示是一种咨询文件，能提供关于患者意愿的清晰且有说服力的证据，因此，患者的意愿能由此得到宪法保护。很明显，未经特别告知的替代判断与患者意愿不太相符。所以，替代决策应以指导性指示（口头或书面的）为指导。现在有可能构建一个实用的、能使益处最大化且风险最小化的、包括指导性规划和赋予代理人权力的预立规划良好临床流程。然而，在预立规划得到广泛且恰当实施之前，我们还有很长的路要走。
