Do Advance Directives Promote More Ethical End-of-Life Care?

An advance directive is a legal document that instructs healthcare providers how you wish to be cared for if you are very ill and unable to speak for yourself. It also designates a healthcare proxy who will have the right to make decisions about your care if you can’t make them yourself. As such, it is a very important tool that helps doctors and other healthcare professionals understand what kinds of care you do and do not want if you are seriously ill. To that extent, it definitely promotes more ethical care. 

With that being said, however, just having an advance directive doesn’t always ensure that a person’s wishes will be carried out. In fact, despite the growing number of seniors who have documented their wishes in an advance directive, studies show that these documents are often inaccessible or ignored. According to a 2010 study published in the Journal of Palliative Medicine, for example, fewer than half of all advance directives actually make it into patients’ charts. What’s more, electronic health records, which were first implemented in the U.S. in the 1960s and ‘70s to improve communication among healthcare providers, have not made finding these documents any easier. Although about 96% of hospitals in the U.S. have adopted EHRs, there is still no consistent location in the medical record where advance directives are stored. 

Perhaps more importantly, an advance directive is a static document that may not address the patient’s wishes at the time a health crisis occurs. People typically prepare an advance directive in advance of a health crisis, believing they can predict what they will want when said crisis occurs. But people, being people, change their minds.  Even a terminally ill person whose advance directive says “Do not resuscitate” may wish to avail themselves of life-saving measures to achieve a new goal (for example, attend a wedding or meet a grandchild for the first time). But in most cases, this change of heart won’t find its way into the advance directive or the EHR. 

Certainly, it is far better to have an advance directive than not to have one. But the best way to ensure that your values and goals are respected when you can’t speak for yourself is to appoint a surrogate who clearly understands what you care about, what’s important to you, and how you would like to be cared for at the end of life, not just in some hypothetical future, but right now. 

Sources

“Advance Directive Completion by Elderly Americans: A Decade of Change”. Journal of the American Geriatrics Society. https://agsjournals.onlinelibrary.wiley.com/doi/abs/10.1111/jgs.12736?referrer_access_token=sMwxEMkBssB1FtMSlXNer4ta6bR2k8jH0KrdpFOxC65I4FZRG-Z9LHoyRde0tFdOgZxECjzfM0WDVXTQWKvZNb5IDrNmpAXqPKEFrluSEOxTQ3IKmbY_MqFRpwtlZ-8T 

“Documentation of Advance Care Planning for Community-Dwelling Elders”. Journal of Palliative Medicine. https://www.liebertpub.com/doi/abs/10.1089/jpm.2009.0341