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Logo of bmjThis ArticleThe BMJ
BMJ. 2007 July 14; 335(7610): 68–69.
PMCID: PMC1914505
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Time to move on from advanced directives

Advance directives promise much but deliver little, writes one doctor from Texas. They were developed more than three decades ago to give patients a say in their future care, but the original concept was overoptimistic. Even the most thorough advanced directive can be derailed in the end by the complexities of modern care, the poor preparation of proxy decision makers, the ambiguity of the patient's wishes, or the strong will of other parties, he writes. Complete control over the manner of death is an unattainable goal.

Despite decades of encouragement, most people fail to complete advanced directives, preferring instead to ignore the uncomfortable reality of death or leave end of life decisions to someone else, or to fate. Even when an advance directive exists, it may not be accessible at a time of crisis. Some are signed once but never updated, leaving relatives unsure of a patient's current wishes.

Some kind of advance care planning will always be important, writes the doctor, but advance directives don't work. Until we come up with something better, doctors should prepare patients and their families for the uncertainty that lies ahead, and support them courageously through difficult decisions when they finally come.


  • Ann Intern Med 2007;147:51-7 [PubMed]

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