Ley de Voluntad Anticipada en Uruguay: una intención loable con algunas inconsistencias / Advance Directive Act in Uruguay: commendable intention with a few inconsistencies / Lei de diretivas antecipadas de vontade no Uruguai: uma intenção louvável com algumas inconsistências

Resumen: La Ley Nº 18.473 y el Decreto que la reglamenta (385/013) fueron concebidos con la finalidad de dar un marco normativo a la posibilidad que tiene una persona de establecer sus preferencias sobre ciertos actos médicos cuando todavía es capaz de consentir, ejerciendo su autonomía de manera anticipada ante la eventual pérdida de capacidad de decisión. Por lo tanto, el hecho de llevar a cabo o no un procedimiento médico no dependerá de la capacidad de consentir de la persona en ese momento, esto es lo que la diferencia del consentimiento informado habitual.

Abstract: Act 18.473 and Decree 385/013 which regulates it, were intended to provide a normative framework for individuals to state their preferences about certain medical acts when they are still capable of consenting to them, exercising their autonomy in advance, in light of the potential loss of their decision-making capacity. Therefore, the fact of performing or not a medical act, will not depend on the consent capacity of the individual at that precise moment, what differentiates it from the regular informed consent. This article aims to analyse the possible inconsistencies between what the law intended to achieve and what is actually authorized today. Certain aspects studied could at least partially explain why this norm is still very hard to enforce even after being effective for over 12 years.

Resumo: A Lei nº 18.473 e o Decreto que a regulamenta (385/013) foram concebidos com o objetivo de dar um marco normativo à possibilidade de uma pessoa estabelecer suas preferências em relação a determinados atos médicos quando ainda está em condições de consentir; exercer previamente a sua autonomia perante a eventual perda da capacidade de decisão. Portanto, a realização ou não de um procedimento médico não dependerá da capacidade da pessoa de consentir naquele momento; isso é o que o torna diferente do consentimento informado usual. O objetivo deste artigo é analisar as possíveis discrepâncias que existem entre o que se pretendia alcançar ao criar a lei e o que realmente pode ser feito. Certos aspectos analisados poderiam explicar, pelo menos em parte, por que essa lei, que já tem mais de 12 anos de sua promulgação, continua sendo muito difícil de implementar.

Living will legislation: between advance healthcare directives and advance care planning, which is the better way to go.

Following drawn out, contentious parliamentary deliberations, the Italian legislature has enacted bill n.219/17, meant to regulate advance healthcare directives. The letter's authors are critical of some key aspects relative to advance directives, contending that it would be preferable to opt for advance care planning, which enables already severely ill patients who are fully aware of the consequences of their disease to choose what therapeutic pathway to undertake.

A More Directive Living Will for Older Adult Patients with End-Stage Medical Conditions?

OBJECTIVES: Many older adult patients want to be treated aggressively for reversible conditions, even when their current quality of life is limited; however, most standard living wills focus on the very end of life and provide little guidance to acute care providers (ACPs) should their older adult patient be admitted with a potentially treatable acute condition and temporarily lose capacity. We developed what we believe is a more informational and directive living will for this population. We sought to determine whether ACPs would find our pilot living will more helpful when caring for their older adult patients. METHODS: Convenience sample of members of the Society of Hospital Medicine (SHM). Respondents were asked to compare the pilot living will with their state form and then answer five attitudinal questions. RESULTS: In total, 125 providers from 39 states completed the survey: 86% indicated that the pilot living will better helped them understand their patients' general end-of-life preferences, 87.5% indicated the pilot living will would be more helpful in making specific treatment decisions for their patients, and 85% indicated the pilot living will would better facilitate end-of-life discussions with surrogates. CONCLUSIONS: Our results suggest that it is possible to design a functional advanced directive that better reflects the wishes of the older adult patient who wants to be treated aggressively in selected clinical situations. By more clearly defining these wishes, acute providers (eg, hospitalists, intensivists) can make more informed, patient-centered recommendations to surrogates.

The Supreme Court of India on euthanasia: Too little, too late.

On Friday, March 9, 2018 the five-judge Constitution Bench (CB) of the Supreme Court of India (SCI) chaired by Dipak Misra, the Chief Justice of India, pronounced its judgment (1) (henceforth CC judgment) granting, for the first time in India, legal recognition to "advanced medical directives" or "living wills", ie, a person's decision communicated in advance on withdrawal of life-saving treatment under certain conditions, which should be respected by the treating doctor/s and the hospital. It also reiterates the legal recognition of the right to "passive euthanasia"; and draws upon Article 21 - the right to life - of the Constitution of India (henceforth Constitution) (2) interpreting robustly that the "right to life" includes the "right to die with dignity". Justices Misra and Khanwilkar disposed of the writ petition filed in 2005 by Common Cause (3) (henceforth CC petition) saying, "The directive and guidelines shall remain in force till the Parliament brings a legislation in the field" (1:p 192).

[Advance directives in clinical practice : Living will, healthcare power of attorney and care directive]. / Vorausverfügungen im klinischen Alltag : Patientenverfügung, Vorsorgevollmacht und Betreuungsverfügung.

In clinical practice, situations continuously occur in which medical professionals and family members are confronted with decisions on whether to extend or limit treatment for severely ill patients in end of life treatment decisions. In these situations, advance directives are helpful tools in decision making according to the wishes of the patient; however, not every patient has made an advance directive and in our experience medical staff as well as patients are often not familiar with these documents. The purpose of this article is therefore to explain the currently available documents (e.g. living will, healthcare power of attorney and care directive) and the possible (legal) applications and limitations in the routine clinical practice.

[Advance directives in clinical practice : Living will, healthcare power of attorney and care directive]. / Vorausverfügungen im klinischen Alltag : Patientenverfügung, Vorsorgevollmacht und Betreuungsverfügung.

In clinical practice, situations continuously occur in which medical professionals and family members are confronted with decisions on whether to extend or limit treatment for severely ill patients in end of life treatment decisions. In these situations, advance directives are helpful tools in decision making according to the wishes of the patient; however, not every patient has made an advance directive and in our experience medical staff as well as patients are often not familiar with these documents. The purpose of this article is therefore to explain the currently available documents (e.g. living will, healthcare power of attorney and care directive) and the possible (legal) applications and limitations in the routine clinical practice.

[Quality of dying processes after commencement of the German Living Will Act : Experiences of a surgical intensive care unit]. / Versterben vor und nach dem "Patientenverfügungsgesetz" : Erfahrungen einer chirurgischen Intensivstation.

BACKGROUND: There is so far no information on how the third act on amendment of the German guardianship law from 29 July 2009 has affected dying processes of critically ill patients. METHODS: This retrospective study analyzed the patterns of dying processes in postoperative critically ill patients treated from 2009 to 2012 (period II after the commencement of the German Living Will Act) and 10 years before (period I, 1999-2002). Independent associations were calculated by logistic regression. RESULTS: In the observation period II (n = 137 dying patients) time until death significantly decreased to 19.3 days (95% CI 14.8-23.8, p = 0.008) vs. 29.2 days (95% CI 23.7-34.6) in period I (n = 163). In period II respect of the patient's will preceded death in 42.3% of the dying patients (period I: 8.6%, p < 0.001). Simultaneously, the frequency of patients with a severe preoperative comorbidity (failure of more than one organ) increased (26.8% of dying patients vs. 5.5% in period I, p = 0.001). The treatment during period II was, in addition to high age and a severe comorbidity, a significant independent predictor for the possibility that respect of the patient's will preceded death (odds ratio 7.42; 95% CI 3.77-14.60). CONCLUSION: Independent of various covariables, treatment after the commencement of the German Living Will Act was associated with a broader and earlier respect of the patient's will, thereby shortening the time until death.

[Each person has to make their own individual decision - arguments for physician assisted suicide]. / Jeder Mensch muss eine individuelle Entscheidung treffen dürfen.

Since November 2015, businesslike assisted suicide is punishable in Germany. But who acts businesslike? The majority of the German population prefers to make own decisions about the circumstances of their arriving death, and many of them would also accept (physician) assisted suicide if necessary. Only a minority of physicians plead for prohibiting assisted suicide in general. In the end everyone should be able to take position on his own. No one is obliged to use or execute assisted suicide.

Why I wrote my advance decision to refuse life-prolonging treatment: and why the law on sanctity of life remains problematic.

This paper, pursuing themes indefatigably defended in this journal and elsewhere by Professors Jenny and Celia Kitzinger, explains what led me to write my own advance decision (AD) to refuse life-prolonging treatment if I become legally incapacitated to make my own healthcare decisions for longer than 3 months and am medically assessed as very unlikely to regain such legal capacity. I attach my Advance Decision to Refuse Life Prolonging Treatment to the online version of this paper for comment advice and possible general interest. I argue that while a Supreme Court judgement in 2013, followed by a Court of Protection judgement in 2015 greatly ameliorate my earlier concerns about excessive judicial emphasis on the sanctity of life, certain current requirements in the Code of Practice to the Mental Capacity Act 2005 and in the Rules of the Court of Protection, especially Practice Direction 9E, concerning permanent vegetative state and minimally conscious state, seem clearly to contradict aspects of that Supreme Court judgement. If the logical implications of those legal requirements were thoroughly implemented medical practice would be substantially and undesirably skewed towards provision of treatments to prolong life that are unwanted, non-beneficial and wasteful of healthcare resources. I urge that these legal requirements are modified to make them consistent with the Supreme Court's judgement in Aintree v James.

Aspectos bioético-jurídicos de las instrucciones previas o testamento vital en el contexto normativo español / Bioethical and legal issues of advance directives or living wills in the context of Spain / Aspectos bioético-jurídicos das instruções prévias ou testamento vital no contexto normativo espanhol

La discrepancia que genera la institución de las instrucciones previas se aprecia en distintos niveles -ético, jurídico social-, y alcanza incluso al ámbito terminológico, esto es, los términos empleados para referirse a esta institución no son en absoluto pacíficos o unívocos: desde testamentos vitales, voluntades o directivas anticipadas, deseos expresados anteriormente, etc., lo que lleva a cierta confusión sobre si se trata o no de la misma figura y a cierta inseguridad jurídica, ámbito por cierto sumamente prolijo en este sentido. No obstante la abundante legislación y doctrina sobre el particular, existe poca información acerca de la forma de registrar el documento, la posibilidad de consultarlo o los límites para su cumplimiento. Este artículo trata de ofrecer mayor luz al respecto, en el seno de la normativa española.

The discrepancy generated by advanced directives is observed in several levels -ethical, legal and social-, and reaches even the terminological field, that is, the terms employed to refer to the issue are not distinct or indifferent at all: from living will to advanced directives to wishes previously expressed, etc., which confers some confusion about whether it refers to the same issue or to some legal insecurity, field otherwise very complex in this sense. In spite of the abundant legislation and doctrine about the issue, there is little information about the way to register the document, the possibility to consult it and the limits about its fulfillment. This article tries to offer more understanding of the issue considering the norms of Spain.

A discrepância que gera a instituição das instruções prévias é apreciada em distintos níveis -ético, jurídico social-, e alcança inclusive o âmbito terminológico, isto é, os termos empregados para se referir a esta instituição não são em absoluto pacíficos ou unívocos: desde testamentos vitais, vontades ou diretivas antecipadas, desejos expressados anteriormente, etc., o que leva a certa confusão sobre se se trata ou não da mesma figura e a certa insegurança jurídica, âmbito por certo sumamente prolixo neste sentido. Não obstante a abundante legislação e doutrina sobre o particular, existe pouca informação acerca da forma de registrar o documento, a possibilidade de consultá-lo ou os limites para seu cumprimento. Este artigo trata de oferecer maior luz a respeito, no seio da normativa espanhola.