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identified. Individual studies suggest that it is possible to have high rates of advance directive documentation (Hammes and Rooney, 1996).3
cultural and legal factors. The influence of cultural values and beliefs on patient and family preferences and behaviors has been suggested above and in Chapter 2. The role of medical culture is evident throughout this report. The most obvious attempt by public officials to support patient preferences is the Patient Self-Determination Act (PSDA). The PSDA is still relatively recent. Its implementation has been complicated and its effects remain uncertain. Chapter 7 considers the PSDA and other legal considerations in end-of-life care, and Chapter 6 considers economic issues. The specific effects of financial incentives on advance care planning have yet to be adequately studied. Cultural differences also appear to play a role both in the individual use of advance directives and physician regard for such directives (Sehgal et al., 1996).
Given this multiplicity of influences on advance care planning and the limited evidence of the effectiveness of written directives, it is not surprising that a number of observers have questioned the emphasis on such documents (see, e.g., Lynn, 1991; Lo, 1995; Solomon, 1995; Emanuel, 1996). One commentator has argued for the testing of more rigorous models of structured decisionmaking that draw on studies of shared decisionmaking that focus on factors that are most amenable to change (Emanuel, 1995b). Others stress the need to change organizational processes, structures, and values. Chapter 5 focuses on such changes in the broader context of efforts to assess and improve the quality of care.
Fitting Care to Goals and Circumstances
Fitting care to patient goals and circumstances involves periodic appraisal by patients, families, clinicians, and others of a number of factors. Box 3.4 highlights questions that will be relevant for most patients, except those whose dying process is so rapid that palliative and other interventions are precluded.
Following a foundation-funded program in La Crosse, Wisconsin, that involved common patient education materials that are available in virtually all of the area's health care institutions, a study found that 85 percent of adult residents who died in the community had written advance directives, 81 percent of the directives were found in the patient's record, and the most common document (77 percent) was a power of attorney for health care (Hammes and Rooney, 1996). Analysis of the experience of decedents with and without some kind of advance directive suggested that patients without directives were somewhat more likely to have resuscitation attempted and to be hospitalized during the last six months of life.