advance directives

Advance Statement

A statement made by an adult at a time when he/she has the capacity to decide for himself/herself about the treatments he/she wishes to accept or refuse, in circumstances in the future when he/she is no longer able to make decisions or communicate his/her preferences

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advance directives 

instructions about a person's wishes, goals, and values regarding what will be done in case he or she becomes incapable of making decisions about medical care; called also living will, durable power of attorney for health care, and sometimes advance health care directives or health care advance directives.

A proxy directive designates another person to make decisions; an instruction directive provides instructions about the person's values and goals or treatment preferences; a combined directive can do both. An instruction directive should focus on goals and values more than on specific medical interventions; interventions can be good in some situations and undesirable in others.

Formal directives are signed and legally authorized written documents. Informal directives are oral communications with family, significant other, or health care provider. Advantages of formal directives are: (1) they are preferences and values more likely to have been carefully considered; (2) they reflect more accurately a person's preferences; (3) they invoke legal practice that commits health care providers to a course of action; and (4) they provide legal enforcement for a person's preferences. Disadvantages include: (1) relatively few people make them or leave explicit directions; (2) identified decision makers might not be available, might be incompetent to make good decisions, or might have a conflict of interest; (3) some people change their preferences regarding treatment but fail to change their directives (and a few, when legally incompetent, protest a surrogate's decision); (4) state laws often severely restrict the use of advance directives; (5) professionals have no basis to overturn instructions that are against the patient's best medical interests, even though the patient might have formulated the instructions without foreseeing a given situation; and (6) some patients do not have an adequate understanding of the decision making needed, or even with an adequate understanding, cannot foresee all clinical situations. Because of inadequate counseling or imprecise language, documents may reflect uninformed preferences.

People often have difficulty identifying decisions and questions delineating adequately the full range of situations that may occur. Because of this, designation of surrogates has become more prevalent. The document can be used for refusal of life sustaining treatment.