Lois A. Weithorn

Domestic Violence and Children: Analysis and Recommendations

Today, domestic violence1 is recognized as a serious societal problem in the United States. Yet, children in families in which such violence occurs have remained largely invisible as victims.2 Concern about children’s exposure to domestic violence3 is increasing, however, in light of a growing body of knowledge regarding the prevalence and effects of childhood exposure to domestic violence. Research suggests that between 3.3 million and 10 million children in the United States are exposed to domestic violence each year.4 And more than a decade of empirical studies indicates that this exposure can have significant negative effects on children’s behavioral, emotional, social, and cognitive development.5

Lost in Translation: The Unintended Consequences of Advance Directive Law on Clinical Care

BACKGROUND Advance directive law may compromise the clinical effectiveness of advance directives. PURPOSE To identify unintended legal consequences of advance directive law that may prevent patients from communicating end-of-life preferences. DATA SOURCES Advance directive legal statutes for all 50 U.S. states and the District of Columbia and English-language searches of LexisNexis, Westlaw, and MEDLINE from 1966 to August 2010. STUDY SELECTION Two independent reviewers selected 51 advance directive statutes and 20 articles. Three independent legal reviewers selected 105 legal proceedings. DATA EXTRACTION Two reviewers independently assessed data sources and used critical content analysis to determine legal barriers to the clinical effectiveness of advance directives. Disagreements were resolved by consensus. DATA SYNTHESIS Legal and content-related barriers included poor readability (that is, laws in all states were written above a 12th-grade reading level), health care agent or surrogate restrictions (for example, 40 states did not include same-sex or domestic partners as default surrogates), and execution requirements needed to make forms legally valid (for example, 35 states did not allow oral advance directives, and 48 states required witness signatures, a notary public, or both). Vulnerable populations most likely to be affected by these barriers included patients with limited literacy, limited English proficiency, or both who cannot read or execute advance directives; same-sex or domestic partners who may be without legally valid and trusted surrogates; and unbefriended, institutionalized, or homeless patients who may be without witnesses and suitable surrogates. LIMITATION Only appellate-level legal cases were available, which may have excluded relevant cases. CONCLUSION Unintended negative consequences of advance directive legal restrictions may prevent all patients, and particularly vulnerable patients, from making and communicating their end-of-life wishes and having them honored. These restrictions have rendered advance directives less clinically useful. Recommendations include improving readability, allowing oral advance directives, and eliminating witness or notary requirements. PRIMARY FUNDING SOURCE U.S. Department of Veterans Affairs and the Pfizer Foundation.

Involving Children in Decisions Affecting Their Own Welfare

The foregoing chapters have provided analyses of legal, psychological, and social issues relevant to children’s “competency” to make decisions affecting their own welfare. Scholars, scientists, and practitioners have focused attention on these issues in response to the courts’ involvement in cases concerning the rights of legal minors to make autonomous decisions. Most publicized have been the United States Supreme Court’s 1979 decisions in the cases of Parham v. J. R.1 and Bellotti v. Baird 2. The first case involved the rights of minors whose parents petition for their admission to psychiatric hospitals. In Bellotti, the Court considered the right of minor females to obtain abortions independent of their parents’ consent.