End-of-life directives: Powers of Attorney, living wills, and other matters

Advance directives were developed as instruments enabling patients to convey their wishes with regard to important treatment attempts after the patients lost their decision making capacity. These directives are based on well established principles in ethics and the law, and have been strongly endorsed by the healthcare profession and the lay public. Nevertheless many problems have emerged. Only a small percentage of patients have completed advanced directives, and often the documents are unavailable or physicians are unaware of them when they are needed. Furthermore, since spouses and other close family members with great familiarity with the patient do not accurately predict the patient's wishes, advance directives that specify only a surrogate decision-maker without providing more detailed instructions about the patient's wishes may not adequately serve the patient. Several important areas need to be refined in regard to advanced directives. First of all the barriers that hinder people from making end-of-life decisions need to be addressed. These barriers come from many sources and will require a broad- based consideration by the healthcare profession if the ideal of patient autonomy is to be supported. It may turn out that certain objections based on cultural beliefs or psychological qualities may limit the application and usefulness of advance directives. Second, it is of utmost importance that the person wishing to complete an advance directive discuss in detail treatment wishes with the chosen surrogate as part of advance care planning and record these wishes, if possible. A general statement of treatment choices provides a broad guideline for agents and physicians, but information about specific situations, procedures, and quality of life examples proved to be invaluable to those who had to make difficult decisions for their loved ones. Third, the advance directive needs to be accessible to the physicians and agent when it is needed. Too often patients put their completed advance directives in safe deposit boxes and forget about them. An agent should have his or her own copy of the advance directive and should assume the responsibility of taking it to the hospital if the patient is unable to do so. Even if a patient has given a copy to his or her physician during an office visit, there is no guarantee that the document will end up in the floor chart where it is needed. Hospitals would do well to implement an on-line computer system that the admitting department of the floor ward clerks could call up whenever a patient is admitted. This system could show at least whether the patient had a DPA and if so whom to call, and it could also indicate the DPA choice or instructions. That would cover anyone who had at some point in time given their doctor a copy of their DPA and had requested it be placed in their permanent medical record. Although patients are not required to have legal documents or indeed any written declaration in order to refuse unwanted treatments, the necessity of some document available in a central location seems warranted by the nature of today's medical care system which involves a multitude of physicians converging on the patient at different times. This is particularly true in the intensive care setting. Thus, despite all the problems with advance directives, and doubts being raised about their value, it is probably premature to give up on the possibility that such documents might serve the patient's best interests and improve the patient's medical care.