The concept of advance directives is rooted in the ethical principle of patient autonomy. Oral statements are recognized ethically, and in some states legally, if properly documented. The documents associated with an advance directive are state-specific, and physicians need to be familiar with the applicable laws in their area. Table 1 provides links to example documents and other resources related to advance directives. The federal Patient Self-Determination Act of requires hospitals, nursing homes, and other facilities to provide information about advance directives to patients and to keep a record of any completed documents.
Regardless of the implementation of these regulations, the rate of advance directive completion has been disappointing, and their value has been questioned. Studies focusing on methods to improve rates of advance directive completion have identified several potential barriers Table 2. Some physicians are uncomfortable with the topic and prefer to wait for the patient to raise the issue. Patient barriers are more varied.
Studies show that lack of interest or knowledge is common, 8 β 10 whereas current health status does not correlate with advance directive completion. Most patients expect the physician to bring up the topic. Cultural, racial, and ethnic factors also play a role in advance directive completion. Black patients are less likely to complete advance directives and are more likely to prefer aggressive care until the end of life.
They are also more likely to cite communication problems with their physicians. Hispanic and Asian patients more often rely on family members for decisions rooted in tradition and spiritual beliefs and thus may not believe that an advance directive is needed. Although recent studies affirm the benefits of advance directives in terms of receiving care congruent with patient preferences, 16 β 18 several problems with implementation have been identified Table 3.
The language used in the documents can be a major barrier to implementation. It is important to note that ill patients may change preferences for or against life-sustaining treatments as their condition worsens. Proxy decision makers are expected to use substituted judgment that relies on the patient's expressed wishes.
