Hong C Y, Goh L G, Lee H P
Department of Community, Occupational and Family Medicine, National University of Singapore, Singapore.
Singapore Med J. 1996 Aug;37(4):411-8.
The advance directive is a document that enables a competent individual to specify the form of health care he would like to have, in the event that he is unable to make such decisions in the future. This review paper traces the development of the advance directive from 1967, when it was first proposed by Luis Kutner. The Karen Ann Quinlan case and the Nancy Cruzan case are cited as examples of the case for the advance directive. The argument is that advance directives assist doctors, patients, family members and other carers with the increasingly complex health care decision making. Reservations have been expressed about the anticipatory nature of the decision, possible conflict with personal and religious ethics and the risk of cost containment considerations being over-riding concerns. The advance directive in America has undergone changes since the California Natural Death Act 1976 was passed. In the 1980s, "terminal" included permanent unconsciousness and advanced dementia. The declarant was also given a wider choice of treatment procedures that they wish to be withheld. Proxy directives were also introduced. In the 1990s, the declarant is even allowed to request the use of life-prolonging procedures. When appropriately implemented, the advance directive can perform its intended functions of clarifying the patient's perspective on life, death and medical care. When it is vague in terminology or applied to patients with uncertain prognoses, it can cause confusion to the patient's carers; and when improperly used, it can become an instrument not of patient's preferences, but of economic purpose, family bias, or physician's values.
预先指示是一份文件，它使有行为能力的个人能够指明在其未来无法做出此类决定时希望接受的医疗保健形式。这篇综述文章追溯了预先指示自1967年首次由路易斯·库特纳提出后的发展历程。凯伦·安·昆兰案和南希·克鲁赞案被引为例证，用以说明预先指示的情况。其论点是，预先指示有助于医生、患者、家庭成员及其他护理人员应对日益复杂的医疗保健决策。对于该决策的前瞻性、可能与个人及宗教伦理的冲突以及成本控制考量可能成为首要关注点等问题，人们已表达了保留意见。自1976年《加利福尼亚自然死亡法》通过以来，美国的预先指示发生了变化。在20世纪80年代，“晚期”包括永久性昏迷和晚期痴呆。声明人对于希望被放弃的治疗程序也有了更广泛的选择。还引入了代理指示。在20世纪90年代，声明人甚至被允许请求使用延长生命的程序。如果实施得当，预先指示能够发挥其预期功能，即阐明患者对生命、死亡和医疗保健的看法。当术语含糊不清或应用于预后不确定的患者时，它可能会给患者的护理人员造成困惑；而当使用不当时，它可能会成为一种并非体现患者偏好，而是出于经济目的、家庭偏见或医生价值观的工具。
