Advance Directives

  • David G. Jacobs


This chapter discusses the issues surrounding advance directives, focusing specifically on the impact these documents may have on the care of the acute care surgical patient. At first, it may seem somewhat unusual to include a chapter on this topic in a text devoted to the care of the acute care surgical patient. However, it is important to remember that acute surgical illness, whether from injury, sepsis, or shock, may render the patient incapable of participating in decision making at the time of presentation. Furthermore, the nature of acute surgical illness not infrequently results in postoperative complications, organ failure, and prolonged intensive care unit stays, requiring invasive and expensive treatment modalities that, for some patients, may be life saving but, for others, may simply be death delaying. Thus, some understanding of the history of advance directives, the types of documents that currently exist, and their relative advantages and disadvantages is necessary to ensure optimal outcomes for this patient population.


Arch Intern Advance Directive Prolonged Intensive Care Unit Stay Make Health Care Decision Substitute Judgment Standard 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Strauss M, ed. Familiar Medical Quotations. Boston: Little, Brown and Company, 1968.Google Scholar
  2. 2.
    Furrow BR GT, Johnson SH, et al. Bioethics: Health Care Law and Ethics, 3rd ed. St. Paul: West Group, 1997.Google Scholar
  3. 3.
    American Hospital Association: A Patient’s Bill of Rights. Chicago: AHA, 1973.Google Scholar
  4. 4.
    Judicial Council of the American Medical Association: Report on Physician and the Dying Patient. Chicago: AMA, 1973.Google Scholar
  5. 5.
    Kutner L. Due process of euthanasia: The living will, a proposal. Ind Law J 1969; 44:539–554.Google Scholar
  6. 6.
    In re Quinlan. Vol 10: 70 NJ; 1976: 355 A.352d647.Google Scholar
  7. 7.
    Cruzan v Director, Missouri Department of Health: 497 U.S. 261, 110 S. Ct. 2841, 111 L.Ed.2d 224; 1990.Google Scholar
  8. 8.
    O’Connor S. 881503 Concur v. Director, Missouri Dept. of Health. 497 US 261 1990. Available at: http://supct. Accessed January 9, 2004.Google Scholar
  9. 9.
    Fairman RP. Withdrawing life-sustaining treatment. Lessons from Nancy Cruzan. Arch Intern Med 1992; 152(1):25–27.Google Scholar
  10. 10.
    Omnibus Reconciliation Act of 1990. Public Law No. 101-508. 1990; Sec. 4206.Google Scholar
  11. 11.
    Chambers CV, Diamond JJ, Perkel RL, Lasch LA. Relationship of advance directives to hospital charges in a Medicare population. Arch Intern Med 1994; 154(5):541–547.CrossRefPubMedGoogle Scholar
  12. 12.
    Weeks WB, Kofoed LL, Wallace AE, Welch HG. Advance directives and the cost of terminal hospitalization. Arch Intern Med 1994; 154(18):2077–2083.CrossRefPubMedGoogle Scholar
  13. 13.
    Schneiderman LJ, Kronick R, Kaplan RM, Anderson JP, Langer RD. Effects of offering advance directives on medical treatments and costs. Ann Intern Med 1992; 117(7): 599–606.PubMedGoogle Scholar
  14. 14.
    Teno J, Lynn J, Connors AF Jr, et al. The illusion of end-of-life resource savings with advance directives. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. J Am Geriatr Soc 1997; 45(4):513–518.Google Scholar
  15. 15.
    Gillick MR. Advance care planning. N Engl J Med 2004; 350(1):7–8.CrossRefPubMedGoogle Scholar
  16. 16.
    Source: Partnership for Caring, Inc; March 2000 Data. Available at: Accessed January 26, 2004.Google Scholar
  17. 17.
    National Conference of Commissioners on Uniform State Laws. Uniform Health-Care Decisions Act. Available at: Accessed January 26, 2004.Google Scholar
  18. 18.
    Gamble ER, McDonald PJ, Lichstein PR. Knowledge, attitudes, and behavior of elderly persons regarding living wills. Arch Intern Med 1991; 151(2):277–280.CrossRefPubMedGoogle Scholar
  19. 19.
    Emanuel LL, Barry MJ, Stoeckle JD, Ettelson LM, Emanuel EJ. Advance directives for medical care-a case for greater use. N Engl J Med 1991; 324(13):889–895.PubMedGoogle Scholar
  20. 20.
    La Puma J, Orentlicher D, Moss RJ. Advance directives on admission. Clinical implications and analysis of the Patient Self-Determination Act of 1990. JAMA 1991; 266(3):402–405.CrossRefPubMedGoogle Scholar
  21. 21.
    Johnson RF Jr, Baranowski-Birkmeier T, O’Donnell JB. Advance directives in the medical intensive care unit of a community teaching hospital. Chest 1995; 107(3):752–756.CrossRefPubMedGoogle Scholar
  22. 22.
    Gross MD. What do patients express as their preferences in advance directives? Arch Intern Med 1998; 158(4):363–365.CrossRefPubMedGoogle Scholar
  23. 23.
    Hanson LC, Rodgman E. The use of living wills at the end of life. A national study. Arch Intern Med 1996; 156(9): 1018–1022.CrossRefPubMedGoogle Scholar
  24. 24.
    Wolf SM, Boyle P, Callahan D, et al. Sources of concern about the Patient Self-Determination Act. N Engl J Med 1991; 325(23):1666–1671.PubMedCrossRefGoogle Scholar
  25. 25.
    Llovera I, Ward MF, Ryan JG, et al. Why don’t emergency department patients have advance directives? Acad Emerg Med 1999; 6(10):1054–1060.CrossRefPubMedGoogle Scholar
  26. 26.
    Teno J, Lynn J, Wenger N, et al. Advance directives for seriously ill hospitalized patients: effectiveness with the patient self-determination act and the SUPPORT intervention. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. J Am Geriatr Soc 1997; 45(4):500–507.PubMedGoogle Scholar
  27. 27.
    Teno JM, Licks S, Lynn J, et al. Do advance directives provide instructions that direct care? SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. J Am Geriatr Soc 1997; 45(4):508–512.PubMedGoogle Scholar
  28. 28.
    The SUPPORT 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(20):1591–1598.Google Scholar
  29. 29.
    Loewy EH, Carlson RW. Talking, advance directives, and medical practice. Arch Intern Med 1994; 154(20):2265–2267.CrossRefPubMedGoogle Scholar
  30. 30.
    White ML, Fletcher JC. The Patient Self-Determination Act. On balance, more help than hindrance. JAMA 1991; 266(3):410–412.CrossRefPubMedGoogle Scholar
  31. 31.
    Doukas DJ. Competency and the routine discussion of advance directives. Am Fam Physician 1992; 45(2):473–474.PubMedGoogle Scholar
  32. 32.
    Frankl D, Oye RK, Bellamy PE. Attitudes of hospitalized patients toward life support: a survey of 200 medical inpatients. Am J Med 1989; 86(6):645–648.CrossRefGoogle Scholar
  33. 33.
    Singer PA, Martin DK, Lavery JV, Thiel EC, Kelner M, Mendelssohn DC. Reconceptualizing advance care planning from the patient’s perspective. Arch Intern Med 1998; 158(8):879–884.CrossRefPubMedGoogle Scholar
  34. 34.
    Reilly BM, Magnussen CR, Ross J, Ash J, Papa L, Wagner M. Can we talk? Inpatient discussions about advance directives in a community hospital. Attending physicians’ attitudes, their inpatients’ wishes, and reported experience. Arch Intern Med 1994; 154(20):2299–2308.CrossRefPubMedGoogle Scholar
  35. 35.
    Annas GJ. The health care proxy and the living will. N Engl J Med 1991; 324(17):1210–1213.PubMedCrossRefGoogle Scholar
  36. 36.
    Cugliari AM, Miller T, Sobal J. Factors promoting completion of advance directives in the hospital. Arch Intern Med 1995; 155(17):1893–1898.CrossRefPubMedGoogle Scholar
  37. 37.
    Markson LJ, Fanale J, Steel K, Kern D, Annas G. Implementing advance directives in the primary care setting. Arch Intern Med 1994; 154(20):2321–2327.CrossRefPubMedGoogle Scholar
  38. 38.
    Morrison RS, Morrison EW, Glickman DF. Physician reluctance to discuss advance directives. An empiric investigation of potential barriers. Arch Intern Med 1994; 154(20): 2311–2318.CrossRefPubMedGoogle Scholar
  39. 39.
    Shmerling RH, Bedell SE, Lilienfeld A, Delbanco TL. Discussing cardiopulmonary resuscitation: a study of elderly outpatients. J Gen Intern Med 1988; 3(4):317–321.CrossRefPubMedGoogle Scholar
  40. 40.
    Havlir D, Brown L, Rousseau GK. Do not resuscitate discussions in a hospital-based home care program. J Am Geriatr Soc 1989; 37(1):52–54.PubMedGoogle Scholar
  41. 41.
    Joos SK, Reuler JB, Powell JL, Hickam DH. Outpatients’ attitudes and understanding regarding living wills. J Gen Intern Med 1993; 8(5):259–263.CrossRefPubMedGoogle Scholar
  42. 42.
    Johnston SC, Pfeifer MP, McNutt R. The discussion about advance directives. Patient and physician opinions regarding when and how it should be conducted. End of Life Study Group. Arch Intern Med 1995; 155(10):1025–1030.CrossRefPubMedGoogle Scholar
  43. 43.
    Kohn M, Menon G. Life prolongation: views of elderly outpatients and health care professionals. J Am Geriatr Soc 1988; 36(9):840–844.PubMedGoogle Scholar
  44. 44.
    McCrary SV, Botkin JR. Hospital policy on advance directives. Do institutions ask patients about living wills? JAMA 1989; 262(17):2411–2414.CrossRefPubMedGoogle Scholar
  45. 45.
    Lo B, McLeod GA, Saika G. Patient attitudes to discussing life-sustaining treatment. Arch Intern Med 1986; 146(8): 1613–1615.CrossRefPubMedGoogle Scholar
  46. 46.
    Tulsky JA, Fischer GS, Rose MR, Arnold RM. Opening the black box: how do physicians communicate about advance directives? Ann Intern Med 1998; 129(6):441–449.Google Scholar
  47. 47.
    Tulsky JA, Chesney MA, Lo B. How do medical residents discuss resuscitation with patients? J Gen Intern Med 1995; 10(8):436–442.CrossRefPubMedGoogle Scholar
  48. 48.
    Roter DL, Larson S, Fischer GS, Arnold RM, Tulsky JA. Experts practice what they preach: a descriptive study of best and normative practices in end-of-life discussions. Arch Intern Med 2000; 160(22):3477–3485.CrossRefPubMedGoogle Scholar
  49. 49.
    Doukas DJ, McCullough LB. The values history. The evaluation of the patient’s values and advance directives. J Fam Pract 1991; 32(2):145–153.PubMedGoogle Scholar
  50. 50.
    Emanuel LL, Emanuel EJ. The Medical Directive. A new comprehensive advance care document. JAMA 1989; 261(22):3288–3293.CrossRefPubMedGoogle Scholar
  51. 51.
    Hickey DP. The disutility of advance directives: we know the problems, but are there solutions? J Health Law 2003; 36(3):455–473.PubMedGoogle Scholar
  52. 52.
    Romero LJ, Lindeman RD, Koehler KM, Allen A. Influence of ethnicity on advance directives and end-of-life decisions. JAMA 1997; 277(4):298–299.CrossRefPubMedGoogle Scholar
  53. 53.
    Blackhall LJ, Murphy ST, Frank G, Michel V, Azen S. Ethnicity and attitudes toward patient autonomy. JAMA 1995; 274(10):820–825.CrossRefPubMedGoogle Scholar
  54. 54.
    Caralis PV, Davis B, Wright K, Marcial E. The influence of ethnicity and race on attitudes toward advance directives, life-prolonging treatments, and euthanasia. J Clin Ethics 1993; 4(2):155–165.PubMedGoogle Scholar
  55. 55.
    Eleazer GP, Hornung CA, Egbert CB, et al. The relationship between ethnicity and advance directives in a frail older population. J Am Geriatr Soc 1996; 44(8):938–943.PubMedGoogle Scholar
  56. 56.
    Mebane EW, Oman RF, Kroonen LT, Goldstein MK. The influence of physician race, age, and gender on physician attitudes toward advance care directives and preferences for end-of-life decision-making. J Am Geriatr Soc 1999; 47(5):579–591.PubMedGoogle Scholar
  57. 57.
    American Medical Association. E-2.225: Optimal Use of Orders—Not-To-Intervene and Advance Directives. April 17, 2003. Available at: Accessed January 22, 2004.Google Scholar
  58. 58.
    Kapp MB. Response to the living will furor: directives for maximum care. Am J Med 1982; 72(6):855–859.CrossRefPubMedGoogle Scholar
  59. 59.
    Grodin MA. Religious advance directives: the convergence of law, religion, medicine, and public health. Am J Public Health 1993; 83(6):899–903.CrossRefPubMedGoogle Scholar
  60. 60.
    Ridley DT. Honoring Jehovah’s Witnesses’ advance directives in emergencies: a response to Drs. Migden and Braen. Acad Emerg Med 1998; 5(8):824–835.CrossRefPubMedGoogle Scholar
  61. 61.
    Kleinman I. Written advance directives refusing blood transfusion: ethical and legal considerations. Am J Med 1994; 96(6):563–567.CrossRefPubMedGoogle Scholar
  62. 62.
    Thompson T, Barbour R, Schwartz L. Adherence to advance directives in critical care decision making: vignette study. BMJ 2003; 327(7422):1011.Google Scholar
  63. 63.
    Brett AS. Limitations of listing specific medical interventions in advance directives. JAMA 1991; 266(6):825–828.CrossRefPubMedGoogle Scholar
  64. 64.
    Silverman HJ, Vinicky JK, Gasner MR. Advance directives: implications for critical care. Crit Care Med 1992; 20(7): 1027–1031.CrossRefPubMedGoogle Scholar
  65. 65.
    Tonelli MR. Pulling the plug on living wills. A critical analysis of advance directives. Chest 1996; 110(3):816–822.CrossRefPubMedGoogle Scholar
  66. 66.
    Coppola KM, Ditto PH, Danks JH, Smucker WD. Accuracy of primary care and hospital-based physicians’ predictions of elderly outpatients’ treatment preferences with and without advance directives. Arch Intern Med 2001; 161(3): 431–440.CrossRefPubMedGoogle Scholar
  67. 67.
    Menikoff JA, Sachs GA, Siegler M. Beyond advance directives-health care surrogate laws. N Engl J Med 1992; 327(16):1165–1169.PubMedCrossRefGoogle Scholar
  68. 68.
    Grisso T. Evaluating Competence. New York: Plenium Press, 1986.Google Scholar
  69. 69.
    Appelbaum PS, Grisso T. Assessing patients’ capacities to consent to treatment. N Engl J Med 1988; 319(25):1635–1638.PubMedCrossRefGoogle Scholar
  70. 70.
    Drane JF. Competency to give an informed consent. A model for making clinical assessments. JAMA 1984; 252(7): 925–927.CrossRefPubMedGoogle Scholar
  71. 71.
    Grisso T, Appelbaum PS, Hill-Fotouhi C. The MacCAT-T: a clinical tool to assess patients’ capacities to make treatment decisions. Psychiatr Serv 1997; 48(11):1415–1419.PubMedGoogle Scholar
  72. 72.
    Tunzi M. Can the patient decide? Evaluating patient capacity in practice. Am Fam Physician 2001; 64(2):299–306.PubMedGoogle Scholar
  73. 73.
    American Medical Association. E-2.20: Withholding or Withdrawing Life-Sustaining Medical Treatment. July 22, 2002. Available at: category/print/8457.html. Accessed January 9, 2004.Google Scholar
  74. 74.
    Yamani M, Fleming C, Brensilver JM, Brandstetter RD. Using advance directives effectively in the intensive care unit. Terminating care in the presence—or absence—of directives. J Crit Illn 1995; 10(7):465–467, 471-473.PubMedGoogle Scholar
  75. 75.
    Teno JM, Stevens M, Spernak S, Lynn J. Role of written advance directives in decision making: insights from qualitative and quantitative data. J Gen Intern Med 1998; 13(7): 439–446.CrossRefPubMedGoogle Scholar
  76. 76.
    Danis M, Southerland LI, Garrett JM, et al. A prospective study of advance directives for life-sustaining care. N Engl J Med 1991; 324(13):882–888.PubMedCrossRefGoogle Scholar
  77. 77.
    Virmani J, Schneiderman LJ, Kaplan RM. Relationship of advance directives to physician-patient communication. Arch Intern Med 1994; 154(8):909–913.CrossRefPubMedGoogle Scholar
  78. 78.
    Fischer GS, Tulsky JA, Rose MR, Siminoff LA, Arnold RM. Patient knowledge and physician predictions of treatment preferences after discussion of advance directives. J Gen Intern Med 1998; 13(7):447–454.CrossRefPubMedGoogle Scholar
  79. 79.
    Teno JM, Lynn J, Phillips RS, et al. Do formal advance directives affect resuscitation decisions and the use of resources for seriously ill patients? SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. J Clin Ethics 1994; 5(1):23–30.PubMedGoogle Scholar
  80. 80.
    Goodman MD, Tarnoff M, Slotman GJ. Effect of advance directives on the management of elderly critically ill patients. Crit Care Med 1998; 26(4):701–704.CrossRefPubMedGoogle Scholar
  81. 81.
    Emanuel EJ, Emanuel LL, Orentlicher D. Advance directives. JAMA 1991; 266(18):2563.CrossRefPubMedGoogle Scholar
  82. 82.
    Morrison RS, Olson E, Mertz KR, Meier DE. The inaccessibility of advance directives on transfer from ambulatory to acute care settings. JAMA 1995; 274(6):478–482.CrossRefPubMedGoogle Scholar
  83. 83.
    Pollack S. A new approach to advance directives. Crit Care Med 2000; 28(9):3146–3148.CrossRefPubMedGoogle Scholar
  84. 84.
    Seckler AB, Meier DE, Mulvihill M, Paris BE. Substituted judgment: how accurate are proxy predictions? Ann Intern Med 1991; 115(2):92–98.PubMedGoogle Scholar
  85. 85.
    Suhl J, Simons P, Reedy T, Garrick T. Myth of substituted judgment. Surrogate decision making regarding life support is unreliable. Arch Intern Med 1994; 154(1):90–96.CrossRefPubMedGoogle Scholar
  86. 86.
    Hare J, Pratt C, Nelson C. Agreement between patients and their self-selected surrogates on difficult medical decisions. Arch Intern Med 1992; 152(5):1049–1054.CrossRefPubMedGoogle Scholar
  87. 87.
    Ouslander JG, Tymchuk AJ, Rahbar B. Health care decisions among elderly long-term care residents and their potential proxies. Arch Intern Med 1989; 149(6):1367–1372.CrossRefPubMedGoogle Scholar
  88. 88.
    Zweibel NR, Cassel CK. Treatment choices at the end of life: a comparison of decisions by older patients and their physician-selected proxies. Gerontologist 1989; 29(5):615–621.PubMedGoogle Scholar
  89. 89.
    Tomlinson T, Howe K, Notman M, Rossmiller D. An empirical study of proxy consent for elderly persons. Gerontologist 1990; 30(1):54–64.PubMedGoogle Scholar
  90. 90.
    Uhlmann RF, Pearlman RA, Cain KC. Physicians’ and spouses’ predictions of elderly patients’ resuscitation preferences. J Gerontol 1988; 43(5):M115–121.PubMedGoogle Scholar
  91. 91.
    Iserson KV. Nonstandard advance directives: a pseudoethical dilemma. J Trauma 1998; 44(1):139–142.CrossRefPubMedGoogle Scholar
  92. 92.
    Fine RL, Mayo TW. Resolution of futility by due process: early experience with the Texas Advance Directives Act. Ann Intern Med 2003; 138(9):743–746.Google Scholar
  93. 93.
    Peterson LM. Advance directives, proxies, and the practice of surgery. Am J Surg 1992; 163(3):277–282.CrossRefPubMedGoogle Scholar
  94. 94.
    Walker RM. DNR in the OR. Resuscitation as an operative risk. JAMA 1991; 266(17):2407–2412.CrossRefPubMedGoogle Scholar
  95. 95.
    Cohen CB, Cohen PJ. Do-not-resuscitate orders in the operating room. N Engl J Med 1991; 325(26):1879–1882.PubMedCrossRefGoogle Scholar
  96. 96.
    Statement of the American College of Surgeons on Advance Directives by Patients. “Do Not Resuscitate” in the operating room. Bull Am Coll Surg 1994; 79(9):29.Google Scholar

Copyright information

© Springer Science+Business Media, LLC 2007

Authors and Affiliations

  • David G. Jacobs
    • 1
  1. 1.Department of SurgeryCarolinas Medical CenterCharlotteUSA

Personalised recommendations