Availability and use of advance directives

Hospitals need to assure themselves that advance directives are available to caregivers, especially physicians, and that the patient's wishes expressed in them are being followed. This can be done only with data collection and analysis and improvement of the processes that support availability and use of advance directives. On a broader, societal perspective, it has been suggested that wide-spread use of advance directives such as natural death act declarations might encourage systematic rationing of healthcare to the elderly. If a right to die becomes a duty to die, the living will and its progeny, the natural death act declaration, will have become a Frankenstein monster. Indeed, in the mid-1980s the suggestion by then-governor Richard Lamm of Colorado, as well as officials at Health and Human Services that the elderly should be required to have living wills raised a storm of protest. Regardless of true motives, such suggestions are often seen as motivated by economics. The hospital must be alert to the ethical issues of advance directives, which are present regardless of a natural death act statute or a living will. Hospitals and their managers must consider these issues prospectively and develop policies that enable them to respect and meet patients' wishes, consistent with the organizational philosophy.