Types of Advance Directives

Advance care planning may lead to written documentation of the patient's wishes. Although this documentation can take the form of a physician's note documenting a discussion, patients often complete written advance directives. These are particularly important in states with formal requirements about the level of evidence surrogates need to forgo treatments or in situations in which conflicts are likely.

There are two types of advance directives: proxy directives and instructional directives. Both proxy and instructional directives are invoked only if the patient has lost decision-making capacity. Proxy directives, often referred to as durable powers of attorney for healthcare, allow patients to specify a person or persons to make decisions. They are relatively easy for physicians and other healthcare providers to discuss with patients and are straightforward for patients to understand. Proxy directives, however, do not indicate the patient's wishes, preferences, or values, and used alone they do not provide any information to the decision makers about what treatments the patient might have wanted under the circumstances at hand.

Instructional directives attempt to fill this gap. These directives, often referred to as living wills, identify situations in which the patient would or would not want specified treatments. For example, a patient's directive might state that "if I am permanently unconscious or terminally ill, I would not want to undergo cardiopulmonary resuscitation." Documents vary in terms of the scenarios described and the specificity of the different treatments. Some documents use general terms such as "heroic measures" or "aggressive care," whereas others list the specific interventions in detail.

Instructional directives apply only under the circumstances specified in the document. If a patient has a directive relating to treatment in the event of permanent unconsciousness, the directive will not help in decision making if that patient has suffered a devastating stroke. Although advance directives often focus on situations in which the patient would want to forgo treatment, they sometimes state circumstances under which a patient would want aggressive treatment. Finally, on some forms, people have the opportunity to provide more comprehensive information about their values and goals in relation both to their lives generally and to medical care specifically.

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