Organizational Planning & Change in Health Administration

Proposal Requiring the Implementation of Advanced Care Directives


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Progress in medical care and technology in the last quarter of 20th century have assisted in prolonging life expectancy in the United States (Silveira, Kim & Langa, 2010). Despite this, the progress have shadowed the margin between life and death, which challenge the anticipation on how American would incident the end of life. There are many individuals who endure traumatic and illnesses that would have been deadly. In others, medical technologies have been serving for prolonged survival within unacceptable superiority of life (Tulsky, 2005). Decisions related with life and death issues tend to impact large and increased number of people in the United States. Evidence has indicated that the treatment of individuals may choose at the end of life mainly is diverse from the treatment received. In most cases, people receive aggressive care which is desired (Ramsaroop, Reid & Adelman, 2007). Despite this, there are individuals especially individuals with disabilities, finding that health care system and their families underrate the quality of life. These results to holding back life-prolonging treatments that are wished by these patients (Tulsky, 2005).

There is individual preference for healthcare facilities where they wish to spend the end of their lives. Most deaths tend to happen in nursing homes or hospitals, but when many individuals are asked they would wish to die at home (Perkins, 2007). Hence, due to this there is the perceptible call for improvement of end of life care in the US. With advance care planning and the utilization of directives, means to make sure that there individual independence at the end of life will be achieved (Silveira, Kim & Langa, 2010). Generally, in the year 1991, Congress passed the Patient Self-Determination Act that was aimed toward encouraging capable individuals to complete the advance directive. Advanced directives are considered as lawful instruments that is used by individuals to highlight the required or preferred treatment and name the surrogate decision maker (well known as the robust control of notary for health care manager) in case there is lose of ability to make health care decisions. Generally, the legislation did not diminish unnecessary forceful cure at the end of life (or related costs), possibly for the reason that advanced directives are underutilized (Ramsaroop, Reid & Adelman, 2007).

This report will present a proposal for change in the health system with the requirement to implement advanced care directives.

Background Outlook on Advance Directives

This issue that relate with the end of life treatment decisions has been of core focus among the public, policy makers and care providers. Historically, decision making related with end of life has been based upon professional influence with assumption that the medical practitioners used to act in the patient best interests (Ramsaroop, Reid & Adelman, 2007). While life saving medical technology advanced, families and individuals, within the realm of consumer rights movement, wanted to condense the utilization of the life-sustaining technique on specific situations. By 1980s, there were increased laws in states that governed the living will. Recognition increased that the legislations did not improve the restriction or application of life-sustaining medical care toward the end of life (Tulsky, 2005).

Significant efforts have been placed toward unifying several state laws that governed advance directives as well as promulgation of advance directive use. Patient Self-Determination was legislated in the year 1990 aimed at encouraging capable adults to complete the advance directive (Perkins, 2007). According to the Act, health care facilities that were receiving Medicare or Medicaid reimbursement were required to request the patients on whether they had the advance directives, provide information about advance directives, and incorporate the advance directives in the medical record (Ramsaroop, Reid & Adelman, 2007). As well, Uniform Health Care Decisions Act of 1993 was legislated aimed at promotion of national model.  By late 90s, state laws were directed toward issue of unwanted recovery for terminally sick patient at home or in hospital with the development of explicit not resuscitate (DNR) directives to be used outside the care facility. The concerns took focus on advance directive portability which caused creation of out-of-hospital DNR protocols in various states (Tulsky, 2005).

Structure and the Application of Advance Directive

Superlatively advance directives are invention of advance care planning. It entails interactive practice between family or person and physicians that assists in determination of the itinerary of a person care and assigns a proxy in making decisions in case capacity is lost (Tulsky, 2005). There are various approaches that have been proposed in facilitation of advance care planning. Such approaches relate with comprehensive elicitation of an individual predilections for treatment on various conditions, aid to identify a proxy, and discovery of values (Silveira, Kim & Langa, 2010).

In the past, only 18-36 percent of the adult population has been able to complete advance directives. People suffering from severe medicinal states are group who can take advance directives as relevant but have only completed advance directives at a slight high rate (Ramsaroop, Reid & Adelman, 2007). Despite the prevalent attempts toward promotion of advance care plan and advance directives, large part of end of life decisions surface after interactions with doctors, individuals, family members, with no formal advance care plan process or the advance directive certificates (Perkins, 2007). Many individuals especially those who lose decision making capability and for individual who require life-sustaining decisions, advance care plan and advance directive completion are crucially significant. Despite this, advance care plan and advance directive completion are exceptional even to individual with dementia, individual whom incapacity tend to develop often while getting medical care (Ramsaroop, Reid & Adelman, 2007).

Conversely, advance directive utilization is higher in some health care setting than in others. Healthcare facilities, mainly the Intensive Care Unit (ICUs), are the most likely facilities where advance directives are used (Perkins, 2007). Despite this, there is evidence that proposes that this is not the case. It set claims that care offered to patients in the ICUs units tends not to kowtow to their advance directives. Inhabitants of nursing homes are more likely to complete advance directives. Even at instances where advance directive subsists, the numerous relocations of patients from one care facilities near the end of life cause portability to be an issue (Ramsaroop, Reid & Adelman, 2007).

The completion rate of advance directive tends to differ depending on ethnicity and race. Issues like access to trust and care in physicians and the health care facilities put in individual motivation to get engaged in advance care plan and completed advance directives (Tulsky, 2005). In addition, the current structures of advance directives have been irreconcilable with various cultural beliefs and traditions. As a matter-of-fact, impediments to some cultural minorities has been the language barrier between the medical practitioner and the patients (Perkins, 2007).

For effective advance directive, it must have reflection on patient preferences. Conversely, patient partialities could change significantly during the course of sickness, with suggestion that the continuing conversations are required (Ramsaroop, Reid & Adelman, 2007).  In fact, advanced directives need to be tailored and appraised to replicate the evolution of patient partialities. As well, agents may not be in a position to comprehend or concur with the patients aspirations. However, proposal may be that, improved communication between agents and individuals tends to improve the agent understanding of advance directives (Ramsaroop, Reid & Adelman, 2007).

Proposals to Promote Advance Completion

There are various intercessions that may be tested in making sure that the proposals to promote engagement in advance care directives are met. Such intercessions will aim at certain aspects of individuals’ health behaviors and the care provider practice pattern (Ramsaroop, Reid & Adelman, 2007). The intercessions are based upon a given model that envisages that the behavioral change is a process that depends upon opportunity, motivation and capacity to change. Major intercessions are educational in character and are directed toward the patients and the care providers. A broader target form of education is the social marketing that has focus on a given population (Perkins, 2007).

Educational Intercessions: the fact is that single and simple client education intercessions that are devised toward increasing knowledge on advance directive would emerge unsuccessful or somehow successful. This is more so in a situation when it comes to increasing advance directive completion or reduction life sustainment treatment usage (Perkins, 2007). Capacity to provide facilitated and more-structured advance care plan intercessions with chronically ill or severely ill ambulatory elderly patients and their care providers would be successful. As well, intercession directed toward improvement of care provider communication skills may have mixed results (Ramsaroop, Reid & Adelman, 2007). In fact, limited effectiveness when it comes to educational efforts in improvement of use of advance directives may be hindered since such efforts are challenging to sustain and the targeted population that is focused may be resistant to changes (Silveira, Kim & Langa, K. 2010).

Social Marketing Intercessions: in social marketing, the implementation and planning of the initiative must be programmed toward coming up with social changes with utilization of concepts part of the commercial marketing (Tulsky, 2005). Such a move would be effective when it comes to achievement of prevalent behavioral changes in relation to health matters. Nevertheless, the application of social marketing toward promotion of advance directives has been new. Within campaigns, promoters must portray increased awareness of the program where they must demonstrate changes in the usage and care provisions (Ramsaroop, Reid & Adelman, 2007).

Multi-component Intercessions: there is the proposal to utilize multi-component where the longitudinal process is employed (Perkins, 2007). This would interrelate with community and intensive interventions that incorporate collaborative advance care planning programs that are effective. Such intervention must incorporate care provider and patient education. Other issues that must be incorporated are the documentation policies and practices to ensure that community anticipations and care provider standards of care are met (Perkins, 2007).


Advance care planning and advanced care directives are crucial tools that assist individuals who are being faced with end of life issues. However, the process of end of life decision making in the state Healthcare facilities has not been well implemented. The fact is that, in the healthcare facilities, patients tend to receive care that is not inconsistent with their wishes. With no exception, health care organizations must consider promoting advance care planning and advanced care directive. As well, they need to come up with meaningful and well-developed measures to ensure that the advance care planning and advanced care directives are successful. Advance care planning will assists patient to receive health care that is in line with their wishes.



Perkins, H. S. (2007). Controlling Death: The False Promise of Advance DirectivesThe False Promise of Advance Directives. Annals of internal medicine, 147(1), 51-57.

Ramsaroop, S. D., Reid, M. C., & Adelman, R. D. (2007). Completing an advance directive in the primary care setting: what do we need for success?. Journal of the American Geriatrics Society, 55(2), 277-283.

Silveira, M. J., Kim, S. Y., & Langa, K. M. (2010). Advance directives and outcomes of surrogate decision making before death. New England Journal of Medicine, 362(13), 1211-1218.

Tulsky, J. A. (2005). Beyond advance directives: importance of communication skills at the end of life. Jama, 294(3), 359-365.









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