Advance directives have been on the American health care scene for over 20 years. Yet, despite their long life and legitimate legal and moral bases, signing rates are still far from universal. If one ascribes to the catch phrase in a popular movie—“if you build it, they will come”—advance directives should have enjoyed great success, rather than being an unexecuted ideal. One would have thought that the publicity surrounding famous cases (e.g., Karen Quinlan and Nancy Cruzan), rulings in state supreme courts safeguarding the rights of individuals to refuse life-sustaining therapies, and state statutes and federal legislation regarding advance directives, would have spurred their use to great heights. Why, then, are advance directives underutilized?
The answer, primarily, is that physicians perceive a great deal of angst about initiating discussions on advance directives, and so—they do not. This reticence is unfortunate, because the impact is ultimately felt by patients, families and physicians.
In his article in this issue of American Family Physician, Aitken1 discusses a methodology that is intended to enhance the execution of advance directives. One crucial point is made: “A physician-initiated discussion of the advance care plan in the outpatient setting is one such important measure.” Yet, many physicians do not initiate such discussions. For example, my colleagues and I surveyed family physicians about the use of the living will and discovered that family physicians had several concerns when they noted that they would not initiate conversations about its use.2 The physicians cited the following reasons for putting off this discussion: discomfort in bringing up the topic, concern about the adverse impression made on their patients and families, and a belief that it was always the responsibility of patients to initiate such conversations (rather than the physician's responsibility).
So, despite the lofty intent of advance directives, the reality is this: internal physician barriers are far more of an encumbrance to the process of advance directives than anything else. The greatest difficulty for physicians is initiating discourse with their patients about advance directives. We need to acknowledge this internal discomfort but move beyond it. Physicians may not want to concede that a patient will die in the future, but it is a reality that we all will die someday.
Advance directives offer a measure of control in the circumstances of one's death. Families sometimes will feel uncomfortable about discussing the future death of a relative, but reminding them about preserving the liberty and dignity of that relative in offering an advance directive is a far greater ethical and legal duty. Although physicians do not want to talk about advance directives, their patients want them addressed.3 It is important to underscore that it is the duty of the physician to offer advance directives.
Given the far-less-than-universal signing rates of advance directives, there seems to be a need to somehow stimulate what has become a failure in the informed consent process. Just as competent adult patients have a right to informed consent or refusal of medical therapies of all kinds, patients also have a right to have information on advance directives presented to them by their physicians.4,5 The recognition of the much greater ethical and legal weight that supports offering advance directives to our patients should help us deal with our own internal dissonance. Physicians then need to work proactively by discussing advance directives with their patients, requesting that patients reflect on their personal values and belief systems to articulate their treatment preferences. Patients must be well informed if they are to be free to discuss their concerns and to be well grounded in their decisions.
Such a process allows for proactive consideration of medical therapies based on the patient's values and attitudes toward future medical conditions. Note that I did not constrain myself to discussion of the latter (i.e., scenarios of illness), but that I also emphasize discussion of the patient's values in this deliberation on advance directives. The importance of values cannot be understated, since physicians need to aggressively evaluate patient values toward end-of-life treatment so that they can adequately articulate their advance directives.6
Patients then must overcome their own greatest hurdle in the advance directive process—procrastination in signing their advance directive. Physicians can play a pivotal role here in reminding the patient that the task of completing an advance directive requires action, unless they want the ambiguity of becoming incapacitated in the future without an advance directive. In several states (Delaware, Michigan, Missouri and New York), not signing an advance directive can be used to rationalize a state interest to preserve life, even when the patient may not have wanted such end-of-life treatment.
Once the advance directive is executed (signed) by the patient, a copy should be placed in the medical chart, with periodic review between the parties, especially if there is a change in health status. When all is said and done, the process for advance directives is not difficult, although it can be made so in the minds of the participants. For physicians, I have but one bit of advice: If you ask, they will tell you.