The Medical Directive. A new comprehensive advance care document

L. L. Emanuel and E. J. Emanuel
General Internal Medicine Unit, Massachusetts General Hospital, Boston, MA 02114.

Living wills have been strongly endorsed in principle. Unfortunately, existing living wills are rarely used in clinical practice because they are vague and difficult to apply. To remedy this, we propose a new advance care document: the Medical Directive. The Medical Directive delineates four paradigmatic scenarios, defined by prognosis and disability of incompetent patients. In each scenario, patients are to indicate their preferences regarding specific life-sustaining interventions. The Medical Directive also provides for the designation of a proxy to make decisions in circumstances where the patient's preferences are uncertain. Finally, there is a section for a statement of wishes regarding organ donation. The Medical Directive provides an opportunity for significant improvement in the documentation of patients' preferences regarding life-sustaining care in states of incompetence. As an expression of a patient's wishes, the Medical Directive should be honored by courts and should facilitate physician-patient discussions of critical and terminal care options.

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Gerontologist 2002;42:51-60.
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End-of-Life Treatment Preferences Among Older Adults
Nahm and Resnick
Nurs Ethics 2001;8:533-543.
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Advance Directives as Acts of Communication: A Randomized Controlled Trial
Ditto et al.
Arch Intern Med 2001;161:421-430.
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Accuracy of Primary Care and Hospital-Based Physicians' Predictions of Elderly Outpatients' Treatment Preferences With and Without Advance Directives
Coppola et al.
Arch Intern Med 2001;161:431-440.
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Experts Practice What They Preach: A Descriptive Study of Best and Normative Practices in End-of-Life Discussions
Roter et al.
Arch Intern Med 2000;160:3477-3485.
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Modal Preferences Predict Elderly Patients' Life-sustaining Treatment Choices as Well as Patients' Chosen Surrogates Do
Smucker et al.
Med Decis Making 2000;20:271-280.
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Conflicts Regarding Decisions to Limit Treatment: A Differential Diagnosis
Goold et al.
JAMA 2000;283:909-914.
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The Stability of Preferences for Life-sustaining Care among Persons with AIDS in the Boston Health Study
Weissman et al.
Med Decis Making 1999;19:16-26.
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Reconceptualizing Advance Care Planning From the Patient's Perspective
Singer et al.
Arch Intern Med 1998;158:879-884.
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The Influence of Physician Explanations on Patient Preferences about Future Health-care States
Mazur and Hickam
Med Decis Making 1997;17:56-60.
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The Dangers of Directives or the False Security of Forms
Hoffmann et al.
J Law Med Ethics 1996;24:5-17.
 

Advance Directives: A Policy-capturing Approach
Raymark et al.
Med Decis Making 1995;15:217-226.
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The Influence of the Probability of Survival on Patients' Preferences Regarding Cardiopulmonary Resuscitation
Murphy et al.
NEJM 1994;330:545-549.
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Continuing Problems with Patient Self-Determination
White et al.
American Journal of Medical Quality 1993;8:187-193.
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Why are Elderly People Not Using Advance Directives?
High
J Aging Health 1993;5:497-515.
ABSTRACT  

Tools for autonomy
Byock
AM J HOSP PALLIAT CARE 1991;8:6-8.
 

Life and Death Choices After Cruzan
Gostin
J Law Med Ethics 1991;19:9-12.
 

The Values History: An Innovation in Surrogate Medical Decision-Making
Lambert et al.
J Law Med Ethics 1990;18:202-212.