Advance directives, proxies, and the practice of surgery

The Patient Self-Determination Act, in effect since December 1991, promises to have a major impact on the practice of surgery. Advance directives will often allow surgery but prohibit the use of resuscitation, ventilators, and artificial feeding. If, however, such interventions are called for as part of an operation or standard postoperative care, should they be utilized despite the prior directive? This article examines this question by reviewing typical surgical cases illustrating the distinction between terminal and advanced illness, the extent of a surgical consent, and differences between proxies and advance directives.