What Advance Directives Satisfy the Patient Self-Determination Act
The Patient Self-Determination Act accepts any healthcare advance directive—whether verbal or written—including conversations, written directives, living wills, or durable power of attorney for health care, though written forms are legally more trustworthy than verbal recollections. 1
Forms of Advance Directives Recognized Under PSDA
The Patient Self-Determination Act of 1990 mandates that healthcare institutions facilitate completion of advance directives if patients desire them, and recognizes multiple formats 1:
Verbal Advance Directives
- Conversations about treatment preferences are legally recognized under PSDA, though courts consider them less trustworthy than written documents 1
- Verbal directives carry less legal weight due to concerns about accurate recollection and interpretation 1
Written Advance Directives
Living Will (Medical Directive/Declaration/Directive to Physicians)
- Provides written direction to healthcare providers about approved care if the patient becomes terminally ill and unable to make decisions 1
- Constitutes evidence of the individual's wishes and is legally enforceable in most jurisdictions 1
- Affects the care received but may not account for unforeseen circumstances 1
Durable Power of Attorney for Health Care
- Appoints an authorized person to make healthcare decisions (not limited to end-of-life decisions) 1
- Accounts for unforeseen circumstances and allows decisions that may conflict with a living will when new situations arise 1
- These decisions are considered valid expressions of the patient's best interests at the time of unforeseen circumstances 1
Comprehensive Healthcare Advance Directive
- Combines the living will and durable power of attorney for health care into one legally binding document 1
- This represents the most complete approach to advance care planning under PSDA 1
Critical Implementation Requirements
Legal Validity Varies by Jurisdiction
- The legal validity of various forms of advance directives differs from state to state 1
- Written advance directives are universally considered more trustworthy than recollections of conversations in court proceedings 1
Institutional Obligations Under PSDA
- Healthcare facilities receiving federal funding must inform patients about advance directives at admission 1
- Institutions must seek and record information regarding advance directives 1
- Facilities must facilitate completion of advance directives if patients desire them 1
Common Pitfalls to Avoid
Timing of Discussions
- Forced contemplation of advance directives at hospital admission may heighten anxiety without revealing true preferences 1
- Discussions should occur before patients become too ill to participate in decisions 1
- Advance directives should be revisited regularly as medical conditions and treatment preferences change over time 1
Documentation and Accessibility
- Advance directives must be properly documented in the medical record 2
- Copies should be given to family, loved ones, and physicians 2
- Mechanisms must ensure healthcare providers can access them across care settings 2
Patient Understanding
- Patients have significant functional health illiteracy about life-sustaining treatments 3, 2
- Physicians must avoid medical jargon and ensure patients understand realistic outcomes 3, 2
Clinical Outcomes Associated with Advance Directives
Quality of Life and Mortality Benefits
- Advance directives are associated with less aggressive medical care near death 1, 3
- Earlier hospice referrals for palliation occur when advance directives exist 1, 3
- Better quality of life and improved caregiver bereavement adjustment result from advance planning 1, 3
- Personal preferences more closely match actual care received when advance directives are present 1