Relationship of general advance directive instructions to specific life-sustaining treatment preferences in patients with serious illness

To determine whether brief general instructions in a typical proxy-instruction advance directive (California Durable Power of Attorney for Health Care [DPAHC]) provide interpretable information about patient requests to limit life-saving treatments, and to determine whether patient treatment preferences are stable over time.

Prospective structured interviews.

University of California, San Diego Medical Center and Veterans Affairs Medical Center, La Jolla.

One hundred four patients (from a randomly chosen sample of 185) with a 5-year life expectancy of no better than 50% as judged by their physicians.

Patients completed the California DPAHC, a proxy-instruction advance directive, at entry and at 1 year. The patients also completed a questionnaire at entry, after 6 months, and after 1 year, indicating their preferences on a five-point Likert-format comparative rating scale for cardiopulmonary resuscitation, mechanical ventilation, artificial nutrition, and hospitalization for pneumonia.

Sixty-eight percent of the subjects executed the DPAHC. Most patients wished treatments to be limited or withheld under certain conditions of reduced quality of life. Although general instructions noted on the DPAHC and preferences regarding specific procedures were stable over the course of a year, the advance directive's general instructions were often inconsistent with, and poor predictors of, specific procedure preferences.

The brief general instruction component of the California DPAHC is not helpful in communicating patient wishes regarding specific life-saving procedures.