The advance directive--a review

Abstract

The advance directive is a document that enables a competent individual to specify the form of health care he would like to have, in the event that he is unable to make such decisions in the future. This review paper traces the development of the advance directive from 1967, when it was first proposed by Luis Kutner. The Karen Ann Quinlan case and the Nancy Cruzan case are cited as examples of the case for the advance directive. The argument is that advance directives assist doctors, patients, family members and other carers with the increasingly complex health care decision making. Reservations have been expressed about the anticipatory nature of the decision, possible conflict with personal and religious ethics and the risk of cost containment considerations being over-riding concerns. The advance directive in America has undergone changes since the California Natural Death Act 1976 was passed. In the 1980s, "terminal" included permanent unconsciousness and advanced dementia. The declarant was also given a wider choice of treatment procedures that they wish to be withheld. Proxy directives were also introduced. In the 1990s, the declarant is even allowed to request the use of life-prolonging procedures. When appropriately implemented, the advance directive can perform its intended functions of clarifying the patient's perspective on life, death and medical care. When it is vague in terminology or applied to patients with uncertain prognoses, it can cause confusion to the patient's carers; and when improperly used, it can become an instrument not of patient's preferences, but of economic purpose, family bias, or physician's values.