Waste No More Young Minds : School districts: Spend all of state windfall on basic instruction and safety

Hospitals and nursing homes are diligent when it comes to some important health matters, particularly finding out whether a new patient has health insurance to pay the bill. But they are far less efficient in the equally important matter of finding out whether a patient has signed a living will, durable power of attorney or other document that specifies what care is to be given or withheld if one becomes comatose or otherwise incapacitated mentally.

At the urging of medical organizations and lawyers, millions of Americans have signed such “advance directives” in recent years. They designate a family member or close friend to make life-and-death decisions and specify when to end or extend life-sustaining efforts. While not foolproof, such documents do help resolve the painful ethical and human dilemmas surrounding the final days or months of a life.

Unfortunately, these explicit directives are often ignored in practice, gathering dust in drawers and safe-deposit boxes. That is the basic conclusion of a study of 180 hospital admissions of elderly patients in New York City published last week in the Journal of the American Medical Assn. All patients had previously signed advance directives, but hospital staff and doctors knew about only a quarter of them. A separate California state study previously found much the same; for three-fourths of California Medicare patients who had executed living wills, medical records showed no indication of that.

The sad fact is that signing a living will or power of attorney has too often turned out to be a waste of time and money. The reasons are complex. Even though a 1990 federal law requires hospitals that get federal funds (nearly all do) to ask all patients whether they have a living will, harried admitting clerks often forget. Also, family members and patients themselves often fail or forget to inform clerks or to bring the document. And, experience suggests, doctors seldom ask about it and usually just consult the most available family member rather than the person legally designated by the patient.

Certainly patients and families should be more assertive about informing doctors and hospital staffs. But, given the stresses and disorientation that normally accompany grave illnesses, the larger burden should fall on doctors. They should be more aggressive in questioning patients about any advance directive--if possible, long before illness strikes--and documenting it clearly in the medical records so that there can be no ambiguity or confusion when the time comes to invoke it.