Families frequently act as substitute decisionmakers for their older members who suffer from diminished mental capacity to make and express their own medical choices. Substitute decisionmaking takes on particular ethical and legal urgency within the nursing home environment, especially when choices concern potential medical treatment near the end of the nursing home resident's life. This article examines current legal mechanisms in the United States that enable a family to make substitute medical decisions, the ethical underpinnings of those mechanisms, and specific (...) ethical and legal considerations implicated by their application to the nursing home setting. The article offers advice to nursing home professionals, including physicians, in working with families as substitute decisionmakers. (shrink)
This paper reports on a mail survey of Jewish nursing homes nationally regarding their compliance with the federal Patient Self-Determination Act that became effective in December, 1991. Data is presented about the extent to which institutions' religious affiliation has influenced their advance directive policies and the procedures they have adopted to implement those policies. A content analysis of written advance directive policies used in Jewish nursing homes is presented also.
The prevailing wisdom is that improving patient access to physician services is essential to promoting the public's health. This article suggests that, ironically, one effect of the 2010 federal health reform legislation may be to discourage physicians from serving the statute's intended beneficiaries, thereby exacerbating the access problem. The article examines several potential approaches to addressing this problem, comparing — from legal and policy perspectives — strategies based on legal conscription of physician services versus strategies that instead would rely on (...) incentivizing physician participation in serving otherwise access-impaired populations. The author argues in favor of the latter approach rather than one based on use of governmental force. (shrink)