Choosing a surrogate to make medical decisions for a patient is an emotionally challenging task. In hospital settings, it is estimated over 86% of life saving medical decisions have been made by a surrogate (Swigart, Lidz, Butterworth, & Arnold, 1996). For the marginalized populations of lesbian, gay men, bisexual, and transgender persons (LGBT), decisions are especially difficult, compounded by issues of discrimination, lack of legal support, level of relationship commitment,, and complicated disclosure to family and medical professionals (Riggle, Rostosky, Prather, & Hamrin, 2005). Limited research has been presented regarding environmental and social factors that impact the choice of a surrogate decision-maker for a LGBT individual. This in-depth literature review will examine factors influencing individual surrogate choice, identify obstacles and gaps in the literature findings, and explore services required by the LBGT population.

Disputes between patients and providers regarding life-sustaining medical treatment (LSMT) are universal across all U.S. states, yet policies regarding these disputes differ significantly. This dissertation determines that all 50 states have advance directive laws that protect a patient’s right to refuse LSMT even when a healthcare provider objects, yet only some states have policies that protect the patient’s right to choose to continue LSMT when a healthcare provider objects (a dispute known as medical futility). Some states have pro-patient laws that protect the patient’s right to make the final decision, while other states have enacted pro-provider medical futility policies that explicitly grant the provider authority to remove LSMT against the patient’s wishes. Finally, in one state, the law delegates the final decision to a third-party: institutional healthcare ethics committees. This dissertation studies the innovation and adoption of these 17 state medical futility policies, examining the theory that values determine both whether the state adopts a medical futility policy as well as what type of medical futility policy a state will adopt- as the policy actors that represent these values: policy entrepreneurs and interest groups. A comparative case study of successful third-party policy adoption in Texas contrasted against a failed effort in Idaho could not affirm the necessity of policy entrepreneurs for policy adoption but did affirm the necessity of interest group consensus and the role of values. Furthermore, quantitative analysis failed to offer statistically-significant evidence of value indicators, but did suggest that government ideology and political party affiliation may potentially become indicators of the type of medical futility policy that states choose to adopt.

Thesis (M.S.)--University of North Dakota, 2005. / Includes bibliographical references (leaves 67-74) Also available online.

Thesis (Ph. D.)--University of Washington, 2001. / Vita. Includes bibliographical references (leaves 212-216).

Professional paper (M Nursing)--Montana State University--Bozeman, 2009. / Typescript. Chairperson, Graduate Committee: Elizabeth S. Kinion. Includes bibliographical references (leaves 28-34).

Thesis (M.A.)--Catholic Theological Union at Chicago, 1998. / Vita. Includes bibliographical references (leaves 117-124).

Thesis (Ph. D.)--University of Rhode Island, 2004. / Typescript. Includes bibliographical references (leaves 171-187).

Background: - Living wills have long been associated with end-of- life care. This study explored the promotion and use of living wills amongst general practitioners and frail care nursing coordinators directly involved in the care of the elderly in Howick, Kwa-Zulu Natal. The study also explored their views regarding the proforma living will disseminated by the Living Will Society. Participants: - Seven general practitioners and three frail care nursing coordinators, making ten in total. Design: - Qualitative in-depth interviews and analysis, using the Framework method. Results:- Both doctors and nursing staff understood the concept of living wills and acknowledged their varied benefits to patient, family and staff. They were concerned about the lack of legal status. They felt that the proforma document from the Living Will Society was simple and clear. Despite identifying the low level of use of living wills, they felt that third party organisations and individuals should promote living wills Conclusion: - GPs and frail care nurse coordinators were knowledgeable of living wills in general and the Living Will Society proforma document in particular. They valued the contribution that living wills can make in the care of the elderly, benefitting patients, their families, health care workers and even the health system. They also valued the proforma living will document from the Living Will Society for its clarity and simplicity. However, both GPs and frail care nursing coordinators viewed the living will process as patient- driven and their main role was as custodians and not advocates of the living will.

Most Americans will die in a hospital or skilled care facility. Despire diligent efforts by local citizens groups, state and national foundations, and healthcare providers to inform the public about their legal rights, only 15% of patients have advanced directives in the form of a living will or health care proxy (Haynor, 1998). Advanced directives that are available are often out-dated, ambiguous, incomplete, unacknowledged, or disregarded by both healthcare providers and family members. An educational program was offered to the residents of a low-income senior housing complex to introduce the "Five Wishes" advanced directive developed by the Commission on Aging with Dignity. The program involved informing the participants about advanced directives, identifying communication strategies for the participants when talking with their physician and family about their wishes, encouraging and assisting participants to complete an advanced directive, and identifying ways to distribute their completed directive. The program was attended voluntarily by thirty-two residents. Results of the anonymous program evaluations revealed the program provided good information about advanced directives, that the information was useful, and that the participants felt more knowledgeable about advanced planning. The majority of participants stated they felt comfortable discussing their wishes with their physician and family, and most wished to complete an advanced directive. Nurse practitioners are in a unique position to provide education, support, and guidance for patients regarding advanced directives. Advanced care planning should be an integral part of the patient's health care. The longitudinal relationships formed through continued health care provision give primary care practitioners the opportunity to help patients remain in control of their care throughout their lives and to keep the patients informed of changes in self-determined healthcare laws and health policies.

An advance directive is an instruction made by a competent person about his or her preferred health care choices, should the person become incapable to make treatment decisions. Legal recognition of advance directives has developed over the last half century in response to medical advances that can prolong the life of a patient who is no longer sentient, and who has decided to forego some or all treatment under such circumstances. Two types of directive have emerged in the law: an instructional directive, in which a person sets out treatment choices, and a proxy directive, which enables the person to appoint a proxy to make treatment decisions. Development of the law has been impeded by fear that advance directives diminish regard for the sanctity of life and potentially authorize euthanasia or assisted suicide. In Canada, this fear explains the continued existence of outdated criminal law prohibitions and contributes to provincial advance directive legislation that is disharmonized and restrictive, in some provinces limiting personal choice about the type of advance directive that can be made. The British Columbia Representation Agreement Act (RAA)1 is an example of such restrictive legislation. The RAA imposes onerous execution requirements, is unduly complex and restricts choice of planning instrument. Respect for patient autonomy requires that health care providers honour patients' prospective treatment preferences. Capable persons must have ready access to a choice of health care planning instruments which can be easily executed. B.C. should implement advance directive legislation that meets the needs and respects the autonomy of B.C. citizens. The Criminal Code must be amended to eliminate physicians' concern about potential criminal liability for following an advance directive. Advance directive legislation across Canada should be harmonized. Finally, health care providers should receive training on effective ways to communicate with patients about end-of-life treatment decisions to ensure that patients' health care choices are known and respected. / Law, Peter A. Allard School of / Graduate