Advance directives: implications for critical care

To discuss the relative merits and limitations of living wills and the durable power of attorney for health care.

Computerized search of MEDLINE.

Studies involving treatment decisions at the end of life and descriptive articles on advance directives.

The recent Cruzan case and passage of the Patient Self-Determination Act have led to an ethical and legal recognition of advance directives, and therefore, critical care practitioners must be familiar with these documents. A living will is a mechanism by which patients can communicate their desires for medical treatment at the end of life. However, the condition that patients be in a "terminal condition," the inability to predict every possible clinical circumstance, and linguistic vagueness have limited the usefulness of living wills. The durable power of attorney for health care overcomes the inherent restrictive weaknesses of living wills, because informed decisions are made by people based on their knowledge of the patient's beliefs and the nuance of the clinical scenario. A concern with this advance directive is that some patients may not know a suitable person to appoint or that the chosen agent may not be available.

We recommend the execution of both a living will and a durable power of attorney for health care to provide the best assurance that patients' desires concerning medical treatments will be respected.