Family physicians' attitudes toward advance directives.

OBJECTIVE: To examine the attitudes toward, the experience with and the knowledge of advance directives of family physicians in Ontario. DESIGN: Cross-sectional survey. PARTICIPANTS: A questionnaire was mailed to 1000 family physicians, representing a random sample of one-third of the active members of the Ontario College of Family Physicians; 643 (64%) responded. RESULTS: In all, 86% of the physicians favoured the use of advance directives, but only 19% had ever discussed them with more than 10 patients. Most of the physicians agreed with statements supporting the use of advance directives and disagreed with statements opposing their use. Of the respondents 80% reported that they had never used a directive in managing an incompetent patient. Of the physicians who responded that they had such experience, over half said that they had not always followed the directions contained in the directive. The proportions of physicians who responded that certain patient groups should be offered the opportunity to complete an advance directive were 96% for terminally ill patients, 95% for chronically ill patients, 85% for people with human immunodeficiency virus infection, 77% for people over 65 years of age, 43% for all adults, 40% for people admitted to hospital on an elective basis and 33% for people admitted on an emergency basis. The proportions of physicians who felt that the following strategies would encourage them to offer advance directives to their patients were 92% for public education, 90% for professional education, 89% for legislation protecting physicians against liability when following a directive, 80% for legislation supporting the use of directives, 79% for hospital policy supporting the use of directives, 73% for reimbursement for time spent discussing directives with patients and 64% for hospital policy requiring that all patients be routinely offered the opportunity to complete a directive at the time of admission. CONCLUSIONS: Family physicians favour advance directives but use them infrequently. Most physicians support offering them to terminally or chronically ill patients but not to all patients at the time of admission to hospital. Although governments emphasize legislation, most physicians believe that public and professional education programs would be at least as likely as legislation to encourage them to offer advance directives to their patients.     

Advance directives: the views of health care professionals.

OBJECTIVES: This study examined the views and experiences of 20 physicians and 20 nurses at a major Canadian teaching hospital regarding the use of advance directives in clinical care. DESIGN: The participants were purposively drawn from four clinical specialties: family and community medicine, oncology, intensive care and geriatrics. Detailed interviews were conducted in person. Content analysis was used to code the data, which were further analysed with both quantitative and qualitative techniques. MAIN RESULTS: Thirty-nine of the 40 participants favoured the use of advance directives in clinical care; physicians had somewhat less positive attitudes than nurses toward such directives. Advance directives were thought by participants to be helpful in resolving disagreements between patients and their families about treatment options; in making patients more comfortable, both physically and psychologically, during the process of dying; and in opening up communication and trust among patients, their families and health care professionals. Concerns about the use of advance directives focused on the lack of clarity in some patients'' instructions, the absence of legal status for directives, the possible interference with a practitioner''s clinical judgement, the adequacy and appropriateness of patients'' information about their circumstances, and the type of intervention (passive or active) requested by patients. CONCLUSIONS: New regulations and legislation are making the use of advance directives more widespread. Health care professionals should participate in the development and implementation of these directives. Continuing professional education is essential in this regard.     

Making an advance directive.

The introduction in Britain of advance directives--which allow a person to state in advance of becoming incompetent that they wish to take part in treatment decisions when no longer mentally competent--has now been advocated by the medical and legal establishments. The practical application of directives relating to health care would be simplified by the adoption of a standard model document together with guidelines summarising the background clinical conditions and any subsequent acute events that may make it appropriate to trigger the use of a directive. As no specific legislation exists, good communication is needed at the various stages between the drafting and implementation of directives if the system of directives is to be successful.     

The Fitness Check of the Birds and Habitats Directives: A discourse analysis of stakeholders’ perspectives

In 2015, the European Union’s Birds and Habitats Directives underwent an evaluation in which selected national stakeholders provided their perspectives on the directives’ implementation. Analyzing the views of different stakeholder groups from eight European member states, this study found that these views could be synthesized into three more general perspectives. The first perspective focuses on problems, indicating that these are caused by legislative drawbacks in the directives. The second perspective holds that problems are generated by improper implementation by member states. The third perspective commends the benefits of the directives in face of the existing implementation problems. Interest groups and to a minor extent governmental bodies espoused the first perspective, and environmental non-governmental organizations especially favored the third. The struggle between these three perspectives reflects ongoing debates regarding positive and negative aspects of the directives and possibilities for improving their implementation. We conclude that the relevance and impact of conservation policies should never be seen as self-evident. In order to reach the conservation goals envisaged, continuous efforts are needed to enforce and maintain environmental legislation.     

The Precautionary Principle: A European Perspective

The ‘precautionary principle’, as formulated in the 1992 Rio Declaration on Environ ment and Development, calls for regulatory action in the face of serious environmental risks even in the absence of full scientific certainty. This paper traces negotiation of the principle at the Rio Conference, and its history in Europe from 1969 Swedish legislation to the latest directives of the European Union. As illustrated by recent court cases from Germany and France, in particular (on nuclear power plants, electro magnetic fields, and genetically modified organisms), judicial interpretation of the principle has tended to be restrictive. Future law making in this field is likely to focus on public access to environmental risk information, and on the development of new ‘right to know’ instru ments such as mandatory product labelling and transnational pollutant release inven tories, an area where Europe can still learn from North American experience.     

Potential conflicts between environmental legislation and conservation exemplified by aquatic macrophytes

It is important that legislation on water quality issues of freshwaters is not in conflict with nature conservation purposes. So far, it is however unknown how the assessment of ecological status according to for example the Water Framework Directive (WFD) of the European Community relates to the status of lakes according to the Habitat Directive (HD) or to national environmental objectives including, e.g., the protection of important wetland areas and red-listed species. We used lake macrophyte classification schemes of Norway, Sweden, and Finland and a total of 1,014 lakes to evaluate the possible conflict between these directives and national legislation. The classification schemes represent mainly trophic indices penalizing lakes with elevated phosphorous concentrations. In general, high ecological status according to the WFD did not mean high number of red-listed species or high status according to the HD or other national environmental objectives. In Sweden 78%, in Norway 47%, and in Finland 29% of lakes with red-listed species were classified as lakes of moderate or worse ecological status based on the macrophyte classification scheme. These lakes thus did not fulfill the demands of the WFD. Restoration of surface water toward fulfilling the demands requires in practice a reduction of the trophic status. This might potentially result in for example the loss of red-listed species. To avoid such potential conflicts, we primarily suggest revising the national quality assessment systems toward implicitly incorporating nature conservation aspects, e.g., the number of red-listed species in a multi-metric assessment system.     

Advancing an advance directive debate

A challenge has recently been levelled against the legal and/or moral legitimacy of some advance directives. It has been argued that in certain cases an advance directive carries no weight in a decision on whether to withhold treatment, since the individual in the debilitating state is not the same person as the person who created the advance directive. In the first section of this paper, I examine two formulations of the argument against the moral legitimacy of the advance directives under review. The second section reviews, and criticizes, an objection to such arguments. In the penultimate section, possible models supporting the viability of the advance directives are considered. The final section makes good on an obligation incurred by the title of the paper.     

Advance directives, dementia, and 'the someone else problem'

Advance directives permit competent adult patients to provide guidance regarding their care in the event that they lose the capacity to make medical decisions. One concern about the use of advance directives is the possibility that, in certain cases in which a patient undergoes massive psychological change, the individual who exists after such change is literally a (numerically) distinct individual from the person who completed the directive. If this is true, there is good reason to question the authority of the directive ‐ which is supposed to apply to the individual who completed it, not to someone else. This is 'the someone else problem'.
After briefly introducing advance directives as a basis for medical decision-making, this paper elaborates 'the someone else problem' in the context of severe dementia. The paper then reconstructs the reasoning that leads to this putative problem and exposes the important underlying assumption that we are essentially persons. An alternative view of what we are, one that regards personhood as inessential, is then considered, before several arguments are advanced in favor of that alternative view. The paper next explores implications for advance directives: 'The someone else problem' is effectively dissolved, while it is noted that a related problem (one beyond the paper's scope) may persist. A few implications beyond advance directives are also identified.     

END‐OF‐LIFE CARE IN THE 21st CENTURY: ADVANCE DIRECTIVES IN UNIVERSAL RIGHTS DISCOURSE

This article explores universal normative bases that could help to shape a workable legal construct that would facilitate a global use of advance directives. Although I believe that advance directives are of universal character, my primary aim in approaching this issue is to remain realistic. I will make three claims. First, I will argue that the principles of autonomy, dignity and informed consent, embodied in the Oviedo Convention and the UNESCO Declaration on Bioethics and Human Rights, could arguably be regarded as universal bases for the global use of advance directives. Second, I will demonstrate that, despite the apparent consensus of ethical authorities in support of their global use, it is unlikely, for the time being, that such consensus could lead to unqualified legal recognition of advance directives, because of different understandings of the nature of the international rules, meanings of autonomy and dignity which are context‐specific and culture‐specific, and existing imperfections that make advance directives either unworkable or hardly applicable in practice. The third claim suggests that the fact that the concept of the advance directive is not universally shared does not mean that it should not become so, but never as the only option in managing incompetent patients. A way to proceed is to prioritize work on developing higher standards in managing incompetent patients and on progressing towards the realization of universal human rights in the sphere of bioethics, by advocating a universal, legally binding international convention that would outlaw human rights violations in end‐of‐life decision‐making.     

End‐of‐life decision‐making and advance care directives in Italy. A report and moral appraisal of recent legal provisions

The present article reviews the state of public debate and legal provisions concerning end‐of‐life decision‐making in Italy and offers an evaluation of the moral and legal issues involved. The article further examines the content of a recent law concerning informed consent and advance treatment directives, the main court pronouncements that formed the basis for the law, and developments in the public debate and important jurisprudential acts subsequent to its approval. The moral and legal grounds for a positive evaluation of this law, which attests that the patient may withhold or withdraw from life‐prolonging treatment, will be offered with reference to liberal approaches and particularly to the frameworks of care and virtue ethics; but reasons will also be offered in order to consider not only the latter but also broader range of end‐of‐life treatment decisions as morally apt options. In this light, we argue in favour of a further development of the Italian legislation to encompass forms of assisted suicide and active euthanasia.     

In Memoriam

The Patient Self-Determination Act was implemented in December 1991. Before and after its implementation, we used a structured interview of 302 randomly selected patients to determine their awareness, understanding, and use of advance directives. Implementation of the Act did not have a major effect on these. Although more than 90% of patients were aware of the living will, only about a third selected the correct definition or the correct circumstances in which it applied, and less than 20% of patients had completed one. About a third of patients were aware of a Durable Power of Attorney for Health Care and chose the correct definition, and about half identified the correct circumstances in which it applies; less than 10% had completed such a document. Surprisingly, patients who said they had completed advance directives did not demonstrate better understanding of these documents. Our results indicate that many patients, including some who have completed advance directives, do not fully understand them. It may be unwise to regard these documents as carefully considered, compelling statements of patients'' preferences. Appropriate responses to our findings include increased public education, revising state statutes to bring them into congruence with public perception, and expanding the dialogue between physicians and patients.     

Intellectual property in natural sciences

The way from scientific finding through invention to production line and finally to the consument is long and expensive and patent should be taken into account. This is evident because the investment connected with the new application needs clear definition of intellectual property rights. Independently what we personally think about patenting in nature sciences--this is a common practice around the world. The positive and negative parameters of patenting are focus on biotechnology. The development of biotechnology is a cumulative effect of co-operation of several disciplines: biology, biochemistry, chemistry, engineering, genetics, medicines and pharmacy and many more. Between not cited here is law and consequently the needs of cooperation between researchers and lawyers. There are several barriers in this co-operation, for example: nomenclature as well as the way of thinking. These borders could be pass only with intercommunication and cross-understanding. The dialog and transfer of knowledge is a must for understanding the nomenclature, terminology of nature by lawyers and by researchers in case of law. Polish legislation concerning intellectually rights is regulated by the law "Prawo w?asno?ci przemys?owej" (30 June, 2000; Dz. U. 2003, Nr 119, pos. 1117, with later amendments). This legislation is related to European Union directives and Munich Convention. Accordingly patenting of product and process is possible in Poland. However, the procedure is time and money consuming, particularly in the case of patent submission in several countries. Amendment of the Polish law to biotechnology made possible patenting of living organism and their parts. It is worth to stress that patented inventions can be used free of charge for research and teaching.     

Acculturation and end-of-life decision making: comparison of Japanese and Japanese-American focus groups

Variation in decision-making about end-of-life care among ethnic groups creates clinical conflicts. In order to understand changes in preferences for end-of-life care among Japanese who immigrate to the United States, we conducted 18 focus groups with 122 participants: 65 English-speaking Japanese Americans, 29 Japanese-speaking Japanese Americans and 28 Japanese living in Japan. Negative feelings toward living in adverse health states and receiving life-sustaining treatment in such states permeated all three groups. Fear of being meiwaku, a physical, psychological or financial caregiving burden on loved ones, was a prominent concern. They preferred to die pokkuri (popping off) before they become end stage or physically frail. All groups preferred group-oriented decision-making with family. Although advance directives were generally accepted, Japanese participants saw written directives as intrusive whereas Japanese Americans viewed them mainly as tools to reduce conflict created by dying person's wishes and a family's kazoku no jo--responsibility to sustain the dying patient. These findings suggest that in the United States Japanese cultural values concerning end-of-life care and decision-making process are largely preserved.     

Graduate medical education as a policy instrument: promise and problems.

Increasingly, graduate medical education (residency training) is being proposed as a policy instrument to reform the traditional manpower problems of distribution of physicians. This article suggests why graduate medical education has become the latest policy device in the decades-old effort to rectify physician imbalances, and it discusses the potential for reform contained in this approach. It then presents a number of problems that will probably hinder the effective implementation of such policy and concludes that future federal policy directives are uncertain.     

Fish diets and the control of eutrophication resulting from aquaculture

Eutrophication of water bodies is an important environmental issue related to aquaculture. Strategies for minimising the impact of aquaculture on the environment include manipulation of diet formulations and selection of raw materials, husbandry practices related to the feeding of fish, effluent water treatment, recovery of uneaten feed and dead fish, and farm site selection. Concerns about the impact of aquaculture on the environment have led to the introduction of legislation in a number of countries, and such legislation is likely to become increasingly important in regulating the aquaculture industry. Whilst legislation on fish diet composition represents one possible regulatory mechanism, such an approach must consider the complexities of fish biology and nutritional requirements, and the many limnological, hydrographic and environmental factors which ultimately determine the degree of eutrophication. This paper & cusses some aspects of fish nutrition and husbandry practices which determine dietary nutrient losses, and considers some aspects and implications of legislation related to diet composition and feed usage.     

Advanced directives. Legal and practical aspects of negative instructions concerning medical treatment

The right of a competent patient to stipulate in advance of possible non-competence, medical treatment he does not want, is based on the fundamental legal principle that a person cannot be medically treated without his informed consent. It is in Dutch law a strong and almost unqualified right. There are indications in the international literature, however, that advance directives in many cases may not have much influence on medical treatment at the end of life. Very little is known about the social practice of advance directives in the Netherlands.     

Canadian outpatients and advance directives: poor knowledge and little experience but positive attitudes.

OBJECTIVE: To examine the knowledge of, previous experience with, attitudes toward and perceived barriers to completing advance directives among outpatients at two general medicine clinics. DESIGN: Cross-sectional questionnaire administered in face-to-face structured interviews. SETTING: General internal-medicine outpatient clinics at a university teaching hospital. PATIENTS: One hundred and five adult outpatients who could communicate in spoken English and who consented to be interviewed. RESULTS: Of 167 patients approached, 58 were excluded because they could not communicate in spoken English, and 4 refused to participate. Of the remaining 105 patients, 17 (16%) knew about living wills, 12 (11%) about durable powers of attorney for health care and 4 (4%) about advance directives. Twenty-three (22%) had thought about their preferences for life-sustaining treatment, 20 (19%) had discussed them, none had written them down, and 45 (43%) had thought about choosing a proxy. Sixty-one (58%) wanted to think about their preferences for treatment, 65 (62%) wanted to discuss them, 32 (30%) wanted to write them down, and 80 (76%) wanted to choose a proxy. The perceived barriers to completing an advance directive were inability to write, the belief that an advance directive was unnecessary, a fatalistic attitude, previous discussion of preferences, a desire to leave the decision to doctors, uncertainty about preferences, a desire to discuss preferences rather than document them, a desire to wait until the situation arose, a desire to write down preferences in the future and a desire to avoid thinking about preferences or advance directives. Respondents with more knowledge of life-sustaining treatments were more likely to want to complete an advance directive. CONCLUSIONS: Outpatients have positive attitudes toward advance directives, but their knowledge and experience are limited. These data underscore the need for patient education and for policies to eliminate the barriers to completing advance directives that patients face.     

‘VAGUE OVIEDO’: AUTONOMY,CULTURE AND THE CASE OF PREVIOUSLY COMPETENT PATIENTS

The paper examines the ethical and legal challenges of making decisions for previously competent patients and the role of advance directives and legal representatives in light of the Oviedo Convention. The paper identifies gaps in the Convention that result in conflicting instructions in cases of a disagreement between the expressed prior wishes of a patient, and the legal representative. The authors also examine the legal and moral status of informally expressed prior wishes of patients unable to consent. The authors argue that positivist legal reasoning is insufficient for a consistent interpretation of the relevant provisions of the Convention and argue that ethical argumentation is needed to provide guidance in such cases. Based on the ethical arguments, the authors propose a way of reconciling the apparent inconsistencies in the Oviedo Convention. They advance a culturally sensitive approach to the application of the Convention at the national level. This approach understands autonomy as a broader, relational consent and emphasizes the social and cultural embeddedness of the individual. Based on their approach, the authors argue that there exists a moral obligation to respect the prior wishes of the patient even in countries without advance directives. Yet it should be left to the national legislations to determine the extent of this obligation and its concrete forms.     

NATURA 2000 – The influence of the European directives on the development of nature-based sport and outdoor recreation in mountain areas

In all member countries of the European Community, the influence of European directives is increasing. This is especially the case with directives on the conservation of natural habitats and wild fauna and flora (European Council Directive 92/43 EEC from 1992 (Council of the European Union 1992) and the directive on the conservation of wild birds (European Council directive 79/409 EEC from 1979 (Council of the European Union 1979). These directives are expected to influence the future development of nature-based sport and outdoor recreation significantly. Many German sport organisations are expecting negative consequences for the future development of nature-based sport in mountain areas. This paper summarises key findings of a study commissioned by the German Sport Association.

This project develops guidelines for the application and interpretation of these directives, as well as for their practicable use and management. The study shows that the potential negative effects of nature-based sport and outdoor recreation activities can be categorised into three general types. Furthermore, large sport events should be evaluated separately in the future. Finally, the crucial role of management plans is discussed, which are essential if NATURA 2000 areas are to be established successfully. The management plan assists in the selection of suitable measures, helps to resolve conflicts, and increases the level of acceptance and its transparency for the public. This paper will demonstrate that the consultation and participation of local people including members of sport and recreational organisations is essential to achieve the best result in the interest of nature conservation in general and conservation of endangered habitats or species specifically.