Autonomy in Long-Term Care

            The determination of the amount of autonomy a person should have is the root of many ethical problems in long-term care.  Patients wish to make their own decisions regarding care they receive in order to feel self-worth and respect, but there is difficulty determining who should make the decisions of futile care: the patient or the provider (Pratt, 2009, p. 328).    While it is fairly common in the long-term care spectrum for patients be incompetent, and therefore, unable to make decisions about their treatment, competency is still very challenging to determine, due to the fact that some patients may be able to make one decision but not others.  This decision is usually made in court, but there are no definite means for determining the competency of the patient because it is a personal judgment (Pratt, 2009, p. 334).

            Long-term care consumers may avoid this unpleasant situation by creating an advance directive to state their wishes when they are fully competent and able to make decisions prior to needing immediate medical care.              While living wills can help to communicate the wishes of the patient of which treatments they wish or do not wish to receive, advance directives are not always recognized by the law, so they do not always ensure these wishes will be carried out, due to the fact that family members can challenge the legality of the document (Pratt, 2009, p. 337). 

            In the case of futile care, a patient can receive care beyond their wishes stated in a living will due to the fact that the facility is not aware of their advance directive, or this care is necessary based on the transfer arrangements from acute care to long-term care or from one institution to another due to the fact that providers are obligated to treat unless told otherwise (Pratt, 2009, p. 340).  These situations directly relate to the debate regarding should the patient or the provider determine the use of futile care, and in both cases, neither the patient nor the provider is solely making the choice.  Ethically, the patient should make all decisions regarding the care they wish to receive, however, if they are deemed incompetent and do not have an advance directive, the provider should have a responsibility to advise the family members, but not to make the decision for the patient.