[Acceptance and validation of advanced directives--ethical and clinical considerations]

Crucial decisions of end-of-life treatment quite often are handed over to machines and other technical capabilities of prolonging life at any cost. Various forms of advance directives have been developed, but not widely accepted by the lay public and rarely recognized by physicians and the health care establishment. We discuss the benefits and risks of different forms of advance directives and present, based on own experience and on evaluating the clinical-ethical and clinical-legal debates, a model combining information on value-and-wish status, the designation of a surrogate decision maker, and a limited number of recommendations or directives for crucial end-of-life decisions. We call for further research on physician's and patient's attitudes towards end-of-life decisions and the development and validation of advance directives, as we feel that it will be the culture of physician-patient interaction rather than legal measures that will change ethical and cultural attitudes and medical procedures.