Advance Directives Evolve to Ensure Better End-of-Life Planning

June 17, 2010 By Amy Sutton

When first developed in the 1970s, advance directives focused on providing specific legal instructions, such as a patient’s wishes to withdraw or withhold life-sustaining treatment in cases of terminal illness or incapacity. The documents helped physicians avoid legal problems associated with fulfilling the patient’s wishes.

The instructions “did not turn out to be very helpful in real clinical situations and tended to be overly simplified,” said Charles Sabatino, a lawyer with the Commission on Law and Aging at the American Bar Association.

He chronicled the history and evolution of advance directives in the June issue of The Milbank Quarterly.

The report also highlighted the increasing use of a protocol called Physician Orders for Life-Sustaining Treatment (POLST), currently in use statewide in 11 states. Although POLST is not an advanced directive, it complements related documents such as a living will or durable power of attorney for .

The use of POLST begins with a discussion about end-of-life care between the and the patient or the designated health care decision maker. The physician records the patient’s and family’s wishes and enters them into the patient’s medical record. The POLST forms travel with the patient, even if he or she is moved another facility.

“Instead of standardizing patient’s wishes, this standardizes the medical orders. That sets the process in the right direction,” Sabatino said. “Medical care operates on standardized doctor’s orders — this process translates patient’s wishes into exactly that.”

In a 2004 survey, 93 percent of emergency medical technicians indicated that POLST orders were useful in determining treatments. EMTs also reported that when POLST orders were present, 45 percent of the time they changed treatment based on the patient’s wishes.

A 2009 Journal of Palliative Medicine survey of hospice personnel found that POLST preferences for treatment were used 98 percent of the time.

“The POLST model is a very good one, and I think it complements the advance directive care planning discussion very well. It allows [advance directives] to be used in a way that makes them practical and implementable by nurses and even emergency medical personnel,” said Ira Byock, M.D., director of palliative medicine at Dartmouth-Hitchcock Medical Center.

In the next 10 years, Sabatino foresees most states adopting POLST as part of the advance care planning process. For health care consumers, he recommends revisiting advance directives whenever the “5 Ds” occur: “Every decade, at the death of a loved one, divorce, new diagnosis or a significant decline in condition — those are the times when it’s more important to think about whether you want to change anything,” he said.

“The message here is to have conversations. Conversations can only help you and your family get the care that you desire and avoid treatments that may be burdensome,” Byock said.

More information: Sabatino CP. The evolution of health care advance planning law and policy. The Milbank Quarterly, 88(2), 2010.

Related Stories

Recommended for you

Drug therapy from lethal bacteria could reduce kidney transplant rejection

August 3, 2017
An experimental treatment derived from a potentially deadly microorganism may provide lifesaving help for kidney transplant patients, according to an international study led by investigators at Cedars-Sinai.

Exploring the potential of human echolocation

June 25, 2017
People who are visually impaired will often use a cane to feel out their surroundings. With training and practice, people can learn to use the pitch, loudness and timbre of echoes from the cane or other sounds to navigate ...

Team eradicates hepatitis C in 10 patients following lifesaving transplants from infected donors

April 30, 2017
Ten patients at Penn Medicine have been cured of the Hepatitis C virus (HCV) following lifesaving kidney transplants from deceased donors who were infected with the disease. The findings point to new strategies for increasing ...

'bench to bedside to bench': Scientists call for closer basic-clinical collaborations

March 24, 2017
In the era of genome sequencing, it's time to update the old "bench-to-bedside" shorthand for how basic research discoveries inform clinical practice, researchers from The Jackson Laboratory (JAX), National Human Genome Research ...

The ethics of tracking athletes' biometric data

January 18, 2017
(Medical Xpress)—Whether it is a FitBit or a heart rate monitor, biometric technologies have become household devices. Professional sports leagues use some of the most technologically advanced biodata tracking systems to ...

Financial ties between researchers and drug industry linked to positive trial results

January 18, 2017
Financial ties between researchers and companies that make the drugs they are studying are independently associated with positive trial results, suggesting bias in the evidence base, concludes a study published by The BMJ ...

1 comment

Adjust slider to filter visible comments by rank

Display comments: newest first

not rated yet Jun 25, 2010
A powerful linkage between individual wishes and POLST is the comprehensive Lifecare Advance Directive (see:, which is designed around health care "outcomes," as opposed to rosters of treatments. Considerable research confirms that health outcomes are at the core of patient wishes. Once a patient identifies threshold-based health outcomes, physicians are better empowered to identify the treatments necessary to secure those outcomes via orders such as POLST. This is a linkage that should not be overlooked in the advance planning process.
- JT McKay, PhD.

Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.