Issue 8 / 7 March 2011

IT’S hard to argue with the theory behind advanced care directives: allowing people to specify the level of medical care they wish to receive ahead of time should help to prevent unnecessary interventions and improve their chance of a peaceful death.

But few things in life, or its ending, are that simple.

How much can doctors really trust an advance care directive when making treatment decisions?

It is, after all, impossible for a directive to cover every scenario that may later arise. And if the document has not been updated for some time, how can the treating clinicians be sure the patient’s views have not changed?

A healthy 60-year-old might declare he wouldn’t want to keep going with any level of physical impairment — 20 years on, he might be more focused on simply having a few more years with his grandchildren.

A recent article in the Journal of Medical Ethics goes further, suggesting that promotion of advance directives might align a little too neatly with moves to contain health costs as the population ages.

Medical ethicist Dr Phillipa Malpas, from the University of Auckland, argues older people are already discriminated against in the health system, with evidence suggesting they are less likely to be offered cardiological investigations or joint replacements than younger patients — despite having more clinical indications for both.

Without careful management, she writes, advanced care directives could make things worse by providing a justification for denying expensive treatments to the elderly.

When ageist attitudes are prevalent in the medical setting, it is not difficult to imagine older individuals being encouraged to articulate (clearly) that they do not want “this” or “that” medical treatment. Rationing health care to older patients could then be justified on the basis that “this is what the patient requested in their advance directive”, Malpas writes.

She also questions the ability of time-poor GPs to provide the information and ask the necessary questions to ensure any directive is made by a truly informed patient.

The GP would need to discuss likely future scenarios and explain possible interventions with their associated risks and benefits, as well as exploring the patient’s personal values and goals, she writes.

So, all that in a level B consult? I don’t think so.

If we really want advance care directives to deliver on their promise of increased patient autonomy and control, it looks as though there may be a bit more work to do.


Jane McCredie is a Sydney-based science and medicine writer, and author of Making girls and boys: inside the science of sex, published by UNSW Press.

Posted 7 March 2011

4 thoughts on “Jane McCredie: Are we headed to the right directive?

  1. Joel Rhee says:

    I think that this shows the danger of imposing a concept such as advance care directives onto entire populations. Advance care directives and planning can be useful tools for communication and decision-making especially in certain contexts and situations: for example, if a person has very strong beliefs about their end-of-life preferences; in patients who are suffering from an end-stage illness with a predictable illness trajectory (eg, dementia or metastatic cancer); or people who have an illness with multiple exacerbations and they feel that really that they have had enough (eg, in patients with end-stage COPD and are not keen on any more ICU admissions).
    Without a careful consideration and a process in which appropriate advance care planning and directives are offered to our patients according to their needs and their contexts, we may end up in a situation where advance care directives and plans become obstacles in decision-making and instruments that divide patients, families, medical practitioners and other health professionals, instead of promoting communication and shared understanding.

  2. Sue says:

    Important not to throw baby out with bathwater. Like most aids, an imprecice tool. We can view an advanced directive as having an important role in family discussions. They will then be the ones to know if it is up to date or not.

  3. rural resident says:

    It is interesting that we often link directives to the aged in our population (although that is the time when end-of-life decisions are considered relevant). As a young adult, I am a promoter of directives so that those “expensive treatments” aren’t expended upon young individuals either. Directives also promote consideration and discussion of medical care wishes – which don’t seem to happen enough and leave families torn by argument and emotion.
    Instances of accident victims or severe illnesses can strike the young as well as the old. It’d be nice to offer treatment to everyone, but there comes a question of resource and equitable allocation of those resources too.
    A classic example is the woman from the US who was kept on numerous support systems for years even though she was brain dead – those resources could have potentially been used to save another life/lives.
    I am not sure directives are necessarily a financial argument about “contain[ing] health costs” either. It seems resources are going to be used and money spent on care no matter what, directives help to determine on whom those resources are spent.
    And “cardiological investigations or joint replacements” (while not being equally offered to all patients) are not often linked to ideas about directives either – particularly in respect to end-of-life/death decisions. Most directives in my understanding are related to DNRs (do not resuscitate orders) and concerns of instigating or stopping particular treatments; such as respiratory gastro-instestinal cardiovascular or other invasive supports.
    While there are ethical questions about directives, directives can/should not be dismissed because these questions exist. …and there will always be work to do when it comes to ethics and medicine.

  4. MG says:

    Honestly, Jane, you could do a bit more research into what is written on an advanced health directive. To quote your example: “A healthy 60-year-old might declare he wouldn’t want to keep going with any level of physical impairment — 20 years on, he might be more focused on simply having a few more years with his grandchildren”.
    This simply cannot be presented as an advance directive. The directions must be specific – condition and situation. As for denying people treatment, that is just absurd. The AHD does not remove a person’s choice. If they are able to speak for themselves they can negate anything they have previously written. If they have given contrary instructions to their appointed or statutory health attorney, the AHD is effectively negated. Then it will come down to clinical decision-making and discussion with the relevent parties. The legislation may vary between states, but the principles are really only those employed in good medical practice. The AHD makes everyone think about, and plan for, the forseeable, that is all, in my opinion.

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