Planning for decisional incapacity. A neglected area in ethics and aging

Practitioners and elderly patients share a common interest in advance planning for future health care decision-making in the event of decisional incapacity. It is argued that advance directives can: assist the elderly person in maximizing self-determination; and help physicians in caring for the elderly and their families by removing conflict potential. Furthermore, the author compares the legal and medical understandings of patient self-determination and the uses of best interest and substituted judgment standards. It is argued that medicine and law differ on the important issues only in degree of emphasis, not in principle. To clarify the issues, a systematic classification of the multiple levels of instruction directives and agent-proxy decision-making models is developed. Finally, it is recommended that health care decision-making for the elderly can be enhanced by encouraging patients to create as much evidence as possible to affirm their preferences and values; and plan the delegation of decisions by appointing a proxy.