Advance directives revisited

An advance directive is an important tool for ensuring appropriate and desired care for persons facing the end of life, yet most Americans do not have an advance directive. In many cases, physicians assume that patients will work with an attorney to develop such documentation, or they may have patients complete a simple form outlining their wishes, but these forms are never updated, do not account for every clinical scenario, or may contain vague terminology, causing confusion and potential conficts. As a result, patients' true wishes may not be implemented, leading them to receive care that is inconsistent with their preferences or is too aggressive for their prognosis. This can cause them to experience undue suffering and lead to healthcare facilities wasting unnecessary resources. Physicians can play an important role in getting patients to complete advance directives and, with a little more effort, can improve the quality of what is included in the executed documents while ensuring these documents remain current. In this article, the authors provide a review of advance care planning and advance directives, outlining the history of advance directives as well as the challenges of obtaining, interpreting, and implementing this documentation, providing two case scenarios to put these challenges in perspective. They also provide a table of the language contained in advance directives that clinicians can use when reviewing end-of-life care with their patients.