Application of United States advance directives on Italian soil

United States medical facilities located overseas must comply with American laws and the laws that govern the host nation. The Patient Self-Determination Act of 1990 is in direct conflict with Italian law. Honoring the advance directives of American patients on Italian soil constitutes a criminal offense for the physician, who is subject to 15 years of imprisonment. In response to issues identified in this case report, hospital staff have taken proactive steps to improve the management of dying patients overseas by establishing clearer hospital instructions education, and training and by better managing the psychosocial concerns of family and staff.