Advance directives in end-stage renal disease inherently involve family and staff

Advance directives (ADs) have a pivotal role in the practice of clinical nephrology. The following discussion reviews our own viewpoint, drawing on the present literature and on many case anecdotes from our own practice. The review focuses on (1) the intrinsic value of ADs; (2) the impact of family and staff on clinical outcome in general; (3) family relationships and medical decision-making, especially in the area of ADs; (4) the importance of communication within families and between families and staff, as characterized in "family meetings"; and (5) the power of reconciliation when family members and staff "let go." In the final analysis, ADs present the opportunity for approaching medical decision making in a manner that can lessen the stress of making difficult decisions for the patient and even promote peace of mind for all concerned family and staff.