Why Patient’s Don’t Have Advance Directives?

I was reading my American Family Physician at the YMCA this weekend, and found an article “Implementing Advance Directives” that prompted me to come home and write this post. I have to admit that I should need to more often and earlier with many of my patients. I need to have a better plan for helping patients successfully and confidently choose to complete both a living will and a durable power of attorney.  A living will outlines you preferences for decisions you want made on your behalf in various circumstances if you are unable to verbalize you own preferences.  A durable power of attorney legally authorizes someone to make health care decisions for you in the circumstances where you are unable to make them for yourself.  These two documents complement each other.  I’ve too often tried to maneuver the minefield of coming to decisions for a patient’s care when they have failed to make their preferences clear and implement a durable power of attorney giving one individual the power to execute those choices. Then an out of town relative shows up to save the day, or a sibling dispute over how to deal with Dad’s terminal illness care happens.  This type of thing is all too common, and makes a stressful time for everyone.  Making your preferences known, putting it in writing, and designating a legal power of attorney helps your loved ones avoid this unnecessary messy and at times ugly scenerio. Both of these documents are crucial to both you and your family to assure that your wishes for decision making about your health are carried out according to your wishes.

Why don’t I do a better job?  I suspect it is a combination of factors.  I think the first is that this is rarely high on a patients list of topics they want to discuss at an office visit.  It is easy to put off this discussion when seemingly more pressing issues are the patient’s expressed reason for the office visit.  Even at physical exam visits, or in the medical coding lingo “preventative care” or “health maintenance” visits, it is alluring to focus on topics that lead to a longer or healthier life rather than a better death experience.  Here is the list of the physician-related barriers to completion of an advance directive listed in the AFP article:

  • Discomfort with the topic.
  • Lack of institutional support.
  • Lack of reimbursement.
  • Lack of time.
  •  Waiting for the patient to initiate the discussion.

In my case it is certainly not discomfort with the subject, and I am not intentionally waiting for the patient to bring up the subject, but lack of time and reimbursement undoubtedly play a role.


In addition most patients really don’t need my help in working through this decision process if they address the issue before there is a crisis. Although there are cultural, personal and ethnic variables that shape our decision making, most of my patients can  really quite quickly and easily work through the process of completion of both a very functional living will and a durable power of attorney without my assistance.  So why doesn’t everyone just do it themselves?  Here are the barriers listed in the AFP article that are patient related:

  • Fear of burdening others, i.e. family or friends.
  • Health Literacy
  • Lack of interest or knowledge of the subject.
  • Spiritual, cultural or racial traditions.
  • Waiting for their physician to initiate the discussion.

So how can you just “Do it yourself?” It’s really easy.  Obvoiusly since you are reading this article you have access to the internet, and everything you need is just a few clicks away.  I encourage you, if you have not already completed these documents, to DO IT NOW:


  1. Down load your state’s Advance Directives at the caringinfo.org site.  This is really easy and you can get everything you need by selecting your state from the list here.
  2. Many states have a form called a POLST form.  This stands for physician orders for live sustaining treatment.  If you use a search engine like Google, and you type in your state + POLST form you will easily find a form to download if your state has a POLST form.  You can get the Washington State form to download easily at WA POLST download.  Many physician offices have these available, just ask your doctor.
  3. For some people a form to help you ascertain your values on this subject and to make your values clear to the individual you choose to have your medical power of attorney is helpful.  The University of New Mexico  Institute for Ethics has published online a non-copyright protected form for you to download.  Some patients will find it helpful to attach this to their advance directive as guidance to their proxy in making decisions in line with their values.

There you have it.  You have no more valid excuses to keep you from completing your own advance directive and living will.  Once you complete it be sure to not keep it a secret.  Give a copy to your physician, to the person you choose as your DPA, and keep a copy handy at your home.   Don’t be a victim of your own procrastination or discomfort with this topic.  If you find it helpful ask questions on the subject up with your personal physician.  Be sure to let them know you have these documents completed.

In my best cheer-leading mantra:  You can do it!  Go – Go – Go!




3 Responses to Why Patient’s Don’t Have Advance Directives?

  1. Emily: This is where having a durable power of attorney comes in. Just a living will is open to debate, etc. If an individual has legal DPA I’ve not heard of a hospital not honoring it. On a rare occasion an ethic committee might rule if the DPA is doing something that seems outrageous, but not otherwise. DrP.

  2. I can’t remember which doctor blog this came from, but it was reported that in some cases doctors and hospitals have not gone with the patient’s documented EOL wishes if family members vehemently protested against it. They were afraid of lawsuits. It must be difficult for the doctor to go ahead with the patient wishes, then be accused of something terrible by the family members.

  3. You’ve clearly outlined some of the physician and patient barriers to completing advance directives and some ways for creating them, Dr. Pullen. In addition to the methods you cite, you can now add MyDirectives.com. MyDirectives is a new, free, HIPAA-compliant online service that simplifies the process of creating always-available, updatable advance directives. I’m part of the MyDirectives team and hope you’ll check out the site at http://mydirectives.com/ and share your thoughts about it with us and your readers.

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