Advance directives: what have we learned so far?

As a result of the recent intense focus on advance directives, it is now possible to resolve several questions. It is clear that instructional directives are best able to represent a patient's wishes in the clinical context if they make use of scenario- and treatment-specific statements, perhaps combined with other types of value statements. Instructional directives are a type of advisory document that can provide clear and convincing evidence regarding a patient's wishes and, as such, the patient's wishes can thereby be constitutionally protected. It is clear that proxy judgments that are not specifically informed are not a good match with patients' wishes. Proxy decisions should, therefore, be guided by instructional directives--verbal or documented. It is now possible to construct a good clinical process for advance planning that is practical, maximizes benefits and minimizes risks, and includes both instructional planning and proxy empowerment. However, we have a long way to go before advance planning is widely and appropriately practiced.