Advance Directives: Two Newer Approaches

Gallo and colleagues¹ reported that most physicians completed an advance directive (AD) following enactment of the Patient Self-Determination Act of 1990, which required most health care facilities to inform adult patients about their right to execute an AD.

But studies have found that only 18% to 36% of Americans have completed an AD. Among those who have, most of their physicians are unaware of the existence of the AD, according to a 2008 report to Congress.²

Traditional ADs have been described as “often too vague to clearly direct the interventions a patient would want in specific illness scenarios” and poorly integrated into patients’ medical records and care.

Commenters on Kenneth Murray’s essays^3,4 suggested 2 newer approaches:

• Physician Orders for Life-Sustaining Treatment(POLST).⁵ This form indicates patient preferences for resuscitation, the focus of interventions and hospital care, and specific treatments. Patients or surrogates complete the form in discussion with their provider.

• The non-profit Aging With Dignity’s Five Wishes, a living will written in everyday language.⁶ The Five Wishes form indicates who the patient wants to make health care decisions, medical treatment preferences, choices for physical comfort, how the patient wants to be treated, and what the patient wants loved ones to know.

“I think the experience-based approaches are better when there is a supportive physician and a supportive family,” said Murray. “But because those approaches are somewhat subjective, I see the value in actual procedure-centered directives, because that is black and white. I guess that either works well, with a physician skilled in their use, and either is problematic if a physician is not supportive.”

In regard to his own end-of-life plans, Murray said, “I have prepared an AD and made sure my wishes are known and documented with everyone who might be involved.”