What are advance directives?

What Are Advance Directives

Advance directives are legally binding documents that communicate a person's healthcare preferences and treatment wishes for situations when they become unable to make decisions themselves, based on the Patient Self-Determination Act of 1990 in the United States. 1

Core Definition and Legal Framework

An advance directive is a legal document that allows individuals to specify their healthcare preferences during periods of incapacity, ensuring their autonomous wishes guide medical care when they cannot speak for themselves. 1 These documents can be verbal or written, though courts consider written directives more legally trustworthy than recollections of conversations. 1

The legal foundation stems from the Patient Self-Determination Act of 1990, which mandates that healthcare institutions facilitate completion of advance directives if patients desire them. 1 The legal validity varies by jurisdiction, making it essential to follow specific state or country laws. 1

Two Primary Types of Advance Directives

Living Will (Medical Directive)

A living will provides written direction to healthcare providers about approved care if the individual becomes terminally ill and unable to make decisions. 1 This document:

• May be called a "medical directive," "declaration," or "directive to physicians" 1
• Constitutes legally enforceable evidence of the individual's wishes in most jurisdictions 1
• Specifies treatment preferences for clearly defined medical situations 1
• Should address critical interventions including dialysis, respirators, resuscitation, organ donation, tube feeding, and intensive care admission 1

Durable Power of Attorney for Health Care

This legal document appoints an authorized person (healthcare proxy or surrogate) to make healthcare decisions on the patient's behalf. 1 Key features include:

• Covers all healthcare decisions, not limited to end-of-life situations 1
• Accounts for unforeseen circumstances that may not be addressed in a living will 1
• The proxy's decisions at the time of unforeseen circumstances are considered valid expressions of the patient's best interests, even if they conflict with the living will 1

Comprehensive Healthcare Advance Directive

A comprehensive advance directive combines both the living will and durable power of attorney into one legally binding document, providing the most complete protection of patient autonomy. 1

Clinical Impact on Patient Outcomes

Advance directives are associated with measurably improved outcomes:

• Less aggressive medical care near death 1, 2
• Earlier hospice referrals for palliation 1, 2
• Better quality of life for patients 1, 2
• Improved caregiver bereavement adjustment 1, 2
• Ensuring personal preferences match actual care received 1
• Reduction in ICU admissions at end of life (from 14% to 0% in one study) 3

More than a quarter of elderly patients require surrogate decision-making at the end of life, making these documents essential. 1, 2

Who Should Complete Advance Directives

All adults aged 18 years and older should complete an advance directive, regardless of current health status, because anyone can face sudden, unexpected life-limiting illness or injury. 2 This recommendation comes from the American College of Cardiology and other major organizations. 2

Priority populations requiring enhanced planning:

• Patients with life expectancy less than one year 2
• Advanced metastatic cancer patients 2
• End-stage cardiac or pulmonary disease 2
• Advanced dementia 2
• Chronic progressive illnesses like heart failure and COPD 2

These high-risk patients should complete actionable medical orders in addition to traditional advance directives. 2

Essential Components to Document

Advance directives must specify preferences for:

• Cardiopulmonary resuscitation (CPR) 2
• Mechanical ventilation 2
• Intensive care unit admission 2
• Artificial nutrition and hydration 1, 2
• Antibiotic use 2
• Healthcare proxy/surrogate decision-maker appointment 2

Critical Implementation Requirements

Regular Review and Updates

Advance directives should be revisited regularly as medical conditions and treatment preferences change over time. 1, 2 These discussions must occur while patients retain decision-making capacity, not after capacity is compromised. 2

The patient may revoke or modify an advance directive at any time, even informally through verbal statements or specific behaviors. 1 However, repetitive reflex-driven gestures should not be interpreted as refusal of treatment. 1

Documentation and Accessibility

Written advance directives must be:

• Properly documented in the medical record 2
• Provided as copies to family, loved ones, and physicians 2
• Accessible to healthcare providers through established mechanisms 2
• Transferable across care settings to ensure continuity 2

Healthcare institutions should inquire upon admission whether patients have advance directives to avoid later confusion. 1

Common Pitfalls and How to Avoid Them

Patient Understanding

Patients have significant functional health illiteracy about life-sustaining treatments. 2 Physicians must:

• Avoid medical jargon 2
• Ensure patients understand realistic outcomes (e.g., CPR has only 15% average survival rate, with 44% of survivors experiencing significant functional decline) 2
• Provide clear explanations of what each intervention actually means 2

Physician Initiative

Only 19% of patients report discussing advance directives with their clinician, and lack of physician initiative is among the most frequently cited barriers. 2, 4 Despite legal mandates, physicians often fail to initiate these conversations. 1, 2

Specificity vs. Vagueness

Advance directives must be specific to clearly defined situations to be legally binding and clinically useful. 1 Vague terminology or application to patients with uncertain prognoses causes confusion for caregivers. 5 The document should address specific treatments rather than general statements. 2

Limitations of Patient Autonomy

A patient can refuse treatment in an advance directive but cannot demand specific treatment if there is no medical indication for it. 1 Healthcare providers are not obliged to provide care when there is scientific and social consensus that treatment is ineffective. 1

When Patients Lack Advance Directives

If no advance directive exists, healthcare providers must determine the patient's presumed will through:

• Documented conversations with family members, close friends, or persons of trust 1
• Communication with doctors, nurses, and others close to the patient 1
• Consensus among all involved persons when possible 1
• Clinical ethics committee consultation if disagreement occurs 1

The authorized representative must implement the presumed will of the patient, not their own preferences or irrelevant considerations. 1