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Advance directives, such as living wills, health care powers of attorney, do-not-resuscitate orders, and mental health care directives, are written legal documents that offer patients the opportunity to reflect upon and provide direction for their future medical care. They are important and useful tools to facilitate discussions between patients, family members, and physicians about end-of-life care choices, and they provide guidance and legal protection in those situations when a patient is no longer capable of declaring care preferences, when critical and difficult treatment decisions need to be made. Following an advance directive facilitates making end-of-life care decisions at the patient’s bedside rather than through contentious court proceedings. More importantly, advance directives are legal mechanisms that reinforce the fundamental professional and moral responsibility of health care providers and institutions to promote and protect patient autonomy, welfare, and dignity.


  • Advance directives are legal mechanisms that reinforce fundamental professional and moral responsibilities of health care providers and institutions to promote and protect patient autonomy, welfare, and dignity. Advance directives are best thought of as the result and documentation of a patient-centered process aimed at extending the rights of patients to guide their medical care, even through periods when they are no longer able to directly participate in decisions about their own care.

This chapter offers an introduction to advance directives, examining the general structure of the various types of advance directives, when they may be triggered, what clinical circumstances and decisions they may cover, and the relative strengths and weaknesses of the different advance directive instruments. Every state has laws describing the types of advance directives available in its jurisdiction, the processes by which such documents may be created and triggered, how and where they can be employed, and the legal protections afforded to care providers and health care facilities that carry out care decisions when guided by such documents. These laws may be supplemented by policies and procedures adopted by your local hospital or health care facility to direct the use of advance directives in your particular setting. Given the unique idiosyncrasies found in different state laws and different facility policies, hospitalists should note that not all varieties of advance directive instruments may be available locally, and the processes used to carry out a particular advance directive may diverge from what is described in this chapter.


The 1960s and 1970s saw a movement toward greater patient participation in health care that resulted in new ways to ensure shared decision making between patients and their physicians. During this time, dramatic medical and technological advances underscored the importance of recognizing and incorporating the goals and values of all patients, while ethicists, the courts, and others came to a consensus that a decisionally capable patient has the right to accept or refuse any type of medical care. However, many persons feared a loss of control may occur if ...

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