Advance directives, also known as living wills, are documents that a person can complete to ensure that health care choices are respected. An advance directive only comes into play if a person cannot communicat

In one situation, nurses indicated that family opposition to the terms of the advance directive was the primary factor that inhibited health care providers from following the patient’s living will. When families contradict the patients wishes, physicians took their views under consideration giving them immense weight. After all, whom does the physician have to answer to? This is why the family disagrees with the advance directive. The family’s decisions usually win out. Dealing with death and suffering on a daily basis does not make it easy for medical professionals to make decisions about removing life support. Most make an effort to be as dispassionate as possible about such situations so that families can make informed decisions. The result is that the profession tends to err on the conservative side.

Emergency circumstances can be another barrier to the implementation of advance directives. The emergency room physician treating an accident victim is not really in a position to halt things immediately when a nurse, looking through the patient’s wallet for people to contact, finds a living will card. If heroic measures are applied in an emergency situation, placing the patient on life-support systems, it is sometimes very difficult to remove them. Some believe that discussing advance directives upon admission to a health care facility is yet another factor. Some would argue that this is the wrong place and the wrong time. The PSDA made it necessary for every patient to be asked, upon admission to a health care institution if they have an advance directive or want to prepare one and to supply them with the forms. Many institutions, reluctant to give the appearance of proselytizing about advance directives, do little to initiate discussions with new patients who do not have them. Many hospital personnel whose job it is to answer questions and help patients execute advance directives have insufficient training. Perhaps the PSDA needs to be modified. The PSDA has, however, increased the public’s knowledge. More still needs to be done. Why, then, should an information giving requirement concerning advance directives be applied not to physicians but to health care institutions? Most would agree that the outpatient setting is the best place and time for such discussion. The physician and patient could discuss this issue one to one before an admission to a hospital or long term care facility. If advance directives are to become an integral part of health care it is essential to implement interventions that would make a difference. What can nurses do if they believe a patient is being treated contrary to the spirit or letter of an advance directive?

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