Questions of limits arise over advance directives

The Patient Self-Determination Act (PSDA) is off and running with very little in the way of complaints from hospitals to date. Word obtained from a few hospitals contacted by Hospital Ethics indicates that, as expected, patients are responsive to rather than frightened by conversations initiated by health care personnel regarding advance directives. Some time will pass before the impact of the PSDA will really be known, in particular, whether more patients will have actually signed advance directives, and whether they will have been followed in the event they are called up for clinical decision making. In the professional literature, however, the place of advance directives--their form and function--in the hospital setting is receiving careful scrutiny, and discussions of when and why advance directives might or should be limited are eliciting suggestions of how the process might be improved. Summaries of these discussions follow.