Who should get an advanced directive?

Who Should Get an Advance Directive

All adults aged 18 years and older should complete an advance directive, regardless of their current health status, because anyone can face sudden, unexpected life-limiting illness or injury that renders them unable to make their own medical decisions. 1

Universal Recommendation for All Adults

• Advance care planning is appropriate for all adults 18 years of age and older, not only those with life-limiting illness. 1
• Healthy and independent individuals can face sudden, unexpected life-limiting illness or injury and should complete traditional advance directives. 1
• More than a quarter of elderly patients require surrogate decision-making at the end of life, making advance directives essential for ensuring patient preferences guide care. 1
• Advance directives are associated with less aggressive medical care near death, earlier hospice referrals, better quality of life, and improved caregiver bereavement adjustment. 1

Priority Populations Requiring Enhanced Advance Care Planning

Patients with Life Expectancy Less Than One Year

Patients who may die within the following year require more intensive advance care planning discussions and should complete actionable medical orders (like POLST forms) in addition to traditional advance directives. 1

This includes patients with:

• Advanced metastatic cancer 1
• End-stage cardiac disease 1
• End-stage pulmonary disease 1
• Advanced dementia 1
• Advanced chronic progressive illness 1

Patients with Chronic Diseases

• Patients with heart failure should have advance directives, as mortality rates are high and over half lack these documents despite the recommendation. 2
• Patients with COPD and other chronic respiratory diseases should complete advance directives, as only 25% entering pulmonary rehabilitation have them despite 94% having opinions about intubation. 1
• Community-dwelling older people with chronic diseases such as hypertension, diabetes, and cardiovascular disease should have advance directives. 3

Cancer Patients

• Cancer patients should have advance directives, though completion rates remain low at only 27% even in tertiary cancer centers. 4
• Advance directives are particularly important for critically ill cancer patients, with higher rates found among older patients with serious diseases. 4

Key Components That Must Be Addressed

Advance directives should include both a living will specifying treatment preferences AND a durable power of attorney for health care appointing a surrogate decision-maker. 1

Essential elements to document:

• Preferences regarding cardiopulmonary resuscitation (CPR) 1
• Mechanical ventilation preferences 1, 2
• Intensive care unit admission wishes 1
• Hemodialysis preferences 2
• Artificial nutrition and hydration 1
• Antibiotic use 1
• Appointment of a healthcare proxy/surrogate decision-maker 1

Critical Implementation Points

Timing and Reassessment

• Advance directives should be revisited regularly as medical conditions and treatment preferences may change over time. 1
• Discussions should occur while patients retain decision-making capacity, not when capacity is already compromised. 1
• Most adult patients who create advance directives do not change their preferences over time, supporting early completion. 1

Documentation and Accessibility

• Written advance directives are more legally trustworthy than recollections of conversations and should be properly documented in the medical record. 1
• Copies should be given to the patient's family, loved ones, and physician with mechanisms ensuring healthcare providers can access them. 1
• Advance directives must be transferable across care settings (hospital, nursing home, home care) to ensure continuity. 1

Common Pitfalls to Avoid

Patient Education Gaps

• Patients have significant functional health illiteracy about life-sustaining treatments: 66% don't know mechanical ventilation is often needed after CPR, 37% think ventilated patients can talk, and 20% think ventilators are oxygen tanks. 1
• Physicians must avoid medical jargon and ensure patients understand the realistic outcomes of interventions like CPR (average survival rate 15%, with 44% of survivors having significant functional decline). 1

Healthcare Provider Barriers

• Only 19% of patients report discussing advance directives with their clinician, and lack of physician initiative is among the most frequently cited barriers. 1, 5
• Healthcare institutions are mandated by the Patient Self-Determination Act of 1990 to facilitate completion of advance directives if patients desire them. 1
• The disturbing nature of the topic is among the least mentioned barriers, so providers should not avoid these discussions out of discomfort. 5

Demographic Considerations

• Advance directives are more common among Caucasians than other ethnic groups, highlighting the importance of considering cultural differences when addressing end-of-life issues. 4
• Being married, higher education, and having cardiovascular disease/stroke are associated with different treatment preferences, requiring individualized discussions. 3