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I agree with Abhay Das (September 2005 JRSM1) that ascertaining patients' views and taking an ethics history increases the likelihood of patients receiving appropriate and acceptable treatment. However, I feel that the suggestion that advanced directives are the best way to extend patients' autonomy in circumstances when they would otherwise be incompetent is perhaps a bit simplistic. Dr Das mentions that there are dangers as well as benefits to advanced directives but he did not expand on this.
When the medical team comes to apply the directive there are no clues to the circumstances in which the orders were written. At the time of writing an advanced directive the patient may well have been vulnerable to coercion and undue influence. However, it can be impossible to assess whether this was the case, which makes assessing the validity of the document difficult.
The language used in an advanced directive is often vague and ambiguous; therefore to apply the directive to a specific decision can be less than easy. It is impossible for patients to foresee every clinical scenario and to predict how they would feel in these circumstances. Furthermore, patients' preferences may change in light of their illness experience. The individual who wrote the directive may be very different to the patient it is applied to because the conditions which call for the use of advanced directive are the very same conditions that alter personality, identity, intentions and interests.
Given these problems with assessing validity and applicability of advanced directives, it is unrealistic to imagine that they can be used in isolation to make clinical decisions at the end of life. They can of course be useful, but need to be regularly reviewed to ensure they express the current wishes of the individual. As the BMA recommends, they should be used as a 'part of a continuing dialogue between the doctor and patient'2,3 and not as a way of avoiding discussing end-of-life decisions.