Advance Directives don't work, but that's OK

Advance Directives - documents that spell out which sorts of medical care a patient would want should he/she become incapacitated in the future - have long been the darlings of HMOs, regulators, and patients' rights groups. But two recent studies have now shown that the use of Advance Directives fail to assure that the "surrogate decision-maker" will make the right decision when the time comes. This failure occurs even when the document itself is supplemented by discussions between the patient and surrogate.

In one study (by Tierney, et al. in the January Journal of General Internal Medicine,) physicians were the surrogate decision maker.  In the other ( by Ditto, et al. in the February 12 issue of the Archives of Internal Medicine,) non-physicians (usually a family member) were the surrogate decision makers.  In both studies, the use of Advance Directives and discussions failed to  improve on the accuracy of the decisions made by surrogate decision makers, as compared to cases in which surrogate decision makers had no Advance Directives to guide their decisions.  The authors of one of these studies (the one by Ditto,) however, noted psychological benefits with the use of Advance directives.

DrRich comments:

To thoughtful people, it should come as a great surprise that Advance Directives aren't all they're cracked up to be.  When you ask a healthy person how bad it would be to have to live for the next 30 years confined to a wheelchair, for instance, he's likely to say that life would no longer be worth living.  But if you ask people who are actually confined to wheelchairs how much they'd mind living another 30 years, they respond far more positively to the prospect.  The fact is, when the time comes to make the tough decisions about medical care that seems completely odious to healthy people, those who are faced with imminent death unless such care is given suddenly have a much more tolerant attitude toward that care.  Advance Directives fail to anticipate this common - and understandable - change in attitude.

Studies like this one will not make any appreciable dent in the movement toward Advance Directives, however.  This is because Advance Directives are viewed by hospitals, insurers, and state and federal regulators as a potentially important cost savings measure.  By encouraging healthy people to limit the medical care they want to receive should they ever become incapacitated, when they actually do become incapacitated you can save a lot of money.  Since the incapacitated patient dies (cheaply) without ever regaining the capacity to change his/her mind; since the surrogate decision-maker is - to the best of their ability - doing exactly what the patient spelled out in writing 5 years ago between sets of tennis; since money which would have been spent is not spent; and since the whole exercise improves the psychological well-being of all involved - well, the fact that the wrong decision may have been made can be overlooked.  To even bring it up would be impolite, not to mention politically incorrect.

June, 2001

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