[Respect for self-determination and use of coercion in the treatment of mentally ill persons: an ethical position statement of the DGPPN]. / Achtung der Selbstbestimmung und Anwendung von Zwang bei der Behandlung psychisch erkrankter Menschen : Eine ethische Stellungnahme der DGPPN.

Respect for patient self-determination is a central ethical principle of medical care. Every person has the right to make decisions regarding his or her health autonomously, even if these decisions appear irrational to third parties. Free and informed consent is the necessary prerequisite for every diagnostic and therapeutic procedure. A patient's ability for self-determination is one requirement for valid consent. In illness, the ability for self-determination may be limited or absent in individual cases. An ethical dilemma arises if severely ill patients who are unable to make autonomous decisions put their health at significant risk and refuse medical procedures in this situation. While non-treatment can be severely detrimental to health, forced procedures can result in traumatization and can damage the relationship of trust between the doctor and patient. The dilemma is intensified in cases of danger to others. In these difficult situations doctors, therapists and nursing staff require ethical guidance for the professional conduct. The primary objective thereby is to avoid coercion. For this purpose recommendations for medical practice are formulated that can reduce the use of forced procedures (e.g. de-escalation procedures, communication competency, clinical ethics counseling, treatment agreements and patient living wills) or if they are unavoidable, that allow them to be conducted in an ethically and legally appropriate way. Further and continued education must pay greater attention to this ethical objective; therefore, for ethical reasons adequate personnel, spatial and structural are vital in hospitals.

The do-not-resuscitate order: associations with advance directives, physician specialty and documentation of discussion 15 years after the Patient Self-Determination Act.

BACKGROUND: Since the passage of the Patient Self-Determination Act, numerous policy mandates and institutional measures have been implemented. It is unknown to what extent those measures have affected end-of-life care, particularly with regard to the do-not-resuscitate (DNR) order. METHODS: Retrospective cohort study to assess associations of the frequency and timing of DNR orders with advance directive status, patient demographics, physician's specialty and extent of documentation of discussion on end-of-life care. RESULTS: DNR orders were more frequent for patients on a medical service than on a surgical service (77.34% vs 64.20%, p = 0.02) and were made earlier in the hospital stay for medicine than for surgical patients (adjusted mean ratio of time from DNR orders to death versus total length of stay 0.30 for internists vs 0.21 for surgeons, p = 0.04). 22.18% of all patients had some form of an advance directive in their chart, yet this variable had no impact on the frequency or timing of DNR ordering. Documentation of DNR discussion was significantly associated with the frequency of DNR orders and the time from DNR to death (2.1 days with no or minimal discussion vs 2.8 days with extensive discussion, p<0.01). CONCLUSIONS: The physician's specialty continues to have a significant impact on the frequency and timing of DNR orders, while advance directive status still has no measurable impact. Additionally, documentation of end-of-life discussions is significantly associated with varying DNR ordering rates and timing.

The Patient Self-determination Act: has it reached the end of its life?

The Patient Self-determination Act requires that patients be informed in writing of their right to accept or refuse treatment and the right to an advance directive. For the past 15 years, hospitals have been providing these written materials, yet advance directives are still not adequately directing end-of-life care. Barriers and facilitators to implementation of this law are discussed, as well as the role of nursing management in meeting its true intent.