Living wills and other advance directives: Reasons for execution and preferences for their use

This dissertation advances our understanding of why individuals execute living wills and durable powers of attorney for health care, and describes how a national legislative policy initiative designed to facilitate and promote the use of these documents was implemented in an urban, tertiary-care teaching hospital.; Those who anticipate serious illness or incapacity can make known in advance their wishes about medical care by filling out either a living will (a document asking that heroic or extraordinary measures to prolong life be avoided) or a durable power of attorney for health care (a document that transfers legal authority to make medical care decisions to another person, usually a trusted relative). These advance directives allow for the prospective exercise of autonomous decision making, yet these "decisions to make decisions" are made in socially dense and organizationally embedded environments that structure the opportunities for and potential symbolic meaning of such action.; The first part of the project is an interview-based case study of an organizational implementation of the Patient Self-Determination Act, which was designed to facilitate such autonomous decision making. Findings support the view that organizational implementation of external mandates is more complex than what the sponsors of such legislation often believe. However, the policies adopted may help legitimate the use of advance directives and thus may help reproduce existing normative ego-ideal expectations of individual control and responsibility.; The second and largest part of the project is a detailed analysis of interviews with over two hundred respondents who had previously executed one or another type of advance directive, used to develop typologies of reasons for execution and preferences for their use, but also to elaborate a theory of personal identity maintenance and symbolic or expressive dimensions of medical-legal decision-making.; The last part of the project presents an analysis of interviews with over one hundred respondents who had never filled out an advance directive. These interviews are used to construct a typology of reasons why advance directives might not be considered, even for those in extremis, and to help foil the identity maintenance arguments advanced throughout the work.*; *This dissertation is a compound document (contains both a paper copy and a CD as part of the dissertation). The CD requires the following system requirements: Microsoft Office.