Is any Advance Directive better than no Advance Directive?

The international awareness of medical Advance Directives, including the power of palliative care, is a great improvement to the end of life process.  But, “Is any Advance Directive (AD) better than no Advance Directive? “   It probably depends on what you are trying to accomplish with the AD.

The number of well-intended websites that help individuals and caregivers create advance directives seems to be increasing on a monthly basis.   The majority of these websites focus on the critical initial conversation regarding what is important to you during your end of life.  The idea is that the more an individual shares about their desires, their wishes, the less stress and anxiety by the family, friends, and caregivers.  Great.  Do these AD documents result in less stress and anxiety and a better end of life? 

What is an AD?

End-of-life planning usually includes making choices about the following:

·        The goals of care (for example, whether to use certain medicines during the last days of life)

·        Where you want to spend your final days

·        Which treatments for end-of-life care you wish to receive

·        What type of palliative care and hospice care you wish to receive

The laws governing advance directives vary from state to state, so it is important to complete and sign advance directives that comply with your state's law.   Also, advance directives can have different titles in different states.  One state’s advance directive does not always work in another state. Some states do honor advance directives from another state; others will honor out-of-state advance directives as long as they are similar to the state's own law; and some states do not have an answer to this question. The best solution is if you spend a significant amount of time in more than one state, you should complete the advance directives for all the states you spend a significant amount of time in

Recent studies have found that there are several key steps to the Advance Directive Process and several life stages that they impact.  Let’s discuss life stages first, as the process is significantly different depending on where you are at because the tools to support the AD process vary depending on where a patient falls on this spectrum:

Healthy -> Potential Life Threatening -> Life Threatening -> Hospice -> End of Life

For a healthy person at the left end of this spectrum, tools regarding goals of care may be considering decisions for comfort versus improved function/rehabilitation versus life prolongation, and the choice of a proxy decision maker(s) who can communicate these values. These tools involve making decisions for hypothetical health states the person has not yet experienced. People who have not experienced a serious event may have a tenuous understanding about the health states for which decisions are being made. These decisions differ from end-of-life decisions because they require people to imagine what life would be like under various conditions of disability, whereas within end-of-life decisions, the patient is directly experiencing the alternative to death.

Based on my research, the majority of website AD tools are designed for healthy people and they produce some great documents.  However, a recent email I received stated that “even if the AD is completed, known, and even accessible (miracle to this point I know) – Is it CONSUMABLE to the ED (Emergency Department) practitioners?  10 page narrative paper or PDF documents are not always very helpful to the busy clinician…. especially if they are at the point of considering life-saving / extending procedures.”   Does this means is that if we do not produce an AD document that is usable by the Emergency Department then it is the same as one does not even exist?

I am very concerned.  What do you think?