Author(s): Eric Warm MD
Background Written advance directives are legal in every stat; laws and forms, however, vary state to state. See Fast Fact #178 for more about the POLST paradigm of advanced directive/treatment orders. There are two general types of advance directives:
Health care power of attorney (‘durable power of attorney for health care,’ ‘health care agent,’ etc.) - a document in which the patient appoints someone to make decisions about his/her medical care if he/she cannot make those decisions.
Living will - a written document in which a patient's wishes regarding the administration of medical treatment are described if the patient becomes unable to communicate at the end of life. Some documents are combinations of the two.
The following are some common misunderstandings that create barriers to properly completing and implementing advance directives.
1. Many physicians believe it is not appropriate to begin advance directive planning on an outpatient basis. In reality multiple studies have shown that patients want their doctors to discuss advance care planning with them before they become ill. Many others have shown a positive response from patients when advance directive discussions are held during outpatient visits.
Overcoming this barrier: When beginning a discussion of advance directives simply ask, “Do you know what an advance directive is? Do you have one?” If you are afraid the patient may respond negatively, perhaps saying to you “Is there something wrong with me? Am I sicker than you are letting on?”, respond by saying, “I ask all of my patients this question, sick or well.” Note, if your practice is in a hospital, the Patient Self Determination Act of 1991 mandates that every person be asked about advance directives when seen (inpatient and outpatient).
2. Many people believe that if a loved one has financial power of attorney he/she doesn’t need a separate medical power of attorney. This is not true. Most often these are separate legal documents.
Overcoming this barrier: When discussing “Power of Attorney” with your patient, assess his/her understanding. Have literature in your office to clear up discrepancies.
3. Many physicians and patients feel that having an advance directive means "don't treat.” Unfortunately advance directives can be a trigger for disengagement by medical staff.
Overcoming this barrier: Make sure your patient and staff understand that advance directives don’t mean "don't treat me". They mean, "treat me the way I want to be treated.”
4. Patients often fear that once a person names a proxy in an advance directive they lose control of their own care.
Overcoming this barrier: When explaining advance directives to your patients make sure they understand that as long as they retain decision making capacity they retain control of their medical destiny. Advance directives only become active when a person cannot speak for him or herself.
5. Many people believe that only old people need advance directives.
Overcoming this barrier: The stakes may actually be higher for younger people if tragedy strikes. Use the example of the Terry Schiavo case as a trigger to enlighten the discussion. Ask – “What would you want if you were in her situation?”
Aitkin PV. Incorporating advance care planning into family practice. American Family Physician. 1999; 59(3):605-14, 617-20.
The SUPPPORT Principal Investigators. A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). JAMA. 1995; 274:1591-1598.
American Bar Association. 10 Legal Myths About Advance Medical Directives. Available at: www.abanet.org/aging/myths.html.
Fast Facts and Concepts are edited by Drew A. Rosielle MD, Palliative Care Center, Medical College of Wisconsin. For more information write to: firstname.lastname@example.org. More information, as well as the complete set of Fast Facts, are available at EPERC: www.eperc.mcw.edu.
Version History: This Fast Fact was originally edited by David E Weissman MD. 2nd Edition published July 2005. Current version re-copy-edited March 2009.
Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Warm E. Myths About Advance Directives, 2nd Edition. Fast Facts and Concepts. July 2005; 12. Available at: http://www.eperc.mcw.edu/EPERC/FastFactsIndex/ff_012.htm.
Disclaimer: Fast Facts and Concepts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Facts cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.
ACGME Competencies: Interpersonal and Communication Skills, Medical Knowledge, Patient Care