The challenge of applying advance directives in hospital practice

Critically ill elderly patients facing crucial decisions about their future medical treatment routinely come under the care of hospital physicians who may have no previous relationship with them or their families. The majority of patients for whom this sort of decision must be made are unable to participate in decision making because of dementia, delirium, or both. They are desperately ill, often with a new medical problem with which they have had little time to come to terms. Hospital physicians must rely on advance directives--either a living will, health care proxy, or both--to make decisions. Translating advance directives into practice is a challenging and complex process that is best approached carefully and systematically.