Advance directives: limitations upon their applicability in elderly care

Advance directives (ADs) are increasingly used and are seen as a way of directing care after the loss of mental capacity. There are, however, major potential problems associated with their use. They may require the withholding of treatment that will alleviate suffering, and have the potential to cause patients to lose abilities and live with unnecessary suffering or handicap. In short, they may fail to achieve what the patient intended, and may cause outcomes that the patient never intended. The requirements for a valid AD are discussed and a simple model for doctors to assess the validity of ADs is proposed. Doctors will need to become much better at understanding the limitations of mental capacity, and quick mechanisms for rebutting ADs will be needed. In general, this is likely to be when ADs appear to conflict with good clinical care and the best interests of the patient. The prospect of legislation on ADs is not welcomed by the author.