Improving advance directives for healthy older people

The quality and quantity of advance directives for healthy older people need to increase. Quality will improve with literal interpretations of do-not-resuscitate orders and more comprehensive directives. Changing the term "DNR" to "No ACLS (Advanced Cardiac Life Support)" should discourage health-care providers from subsuming other limitations under the directive to withhold resuscitation. Other aggressive medical and surgical interventions should be prospectively considered in addition to resuscitation. The quantity of advance directives will increase when physicians feel motivated to devote time and expertise to thorough discussions of advance directives. Although education and legislation will motivate physicians to some extent, their roles are limited. Fair reimbursement for this primary-care service is the most effective motive. The initial investment by Medicare may save large sums in the long run by reducing expensive, undesired care for older people.