Dr. Gillick [1] makes a case for broadening the scope of effective advance medical planning and addresses the difficulties and barriers that are involved. She offers important observations, insights, and recommendations, but her focus is on medical care for the elderly. In fact, patients of all ages can benefit from advance planning.

Progress in this realm has been disappointing, but we may be aiming too high. The literature is replete with calls for advance planning based on models that may be too daunting for most practicing physicians. Lengthy discussions about difficult issues are unlikely to occur in the face of time pressures, other practical concerns, and the presence of psychological resistance. Patients ready to discuss plans for future medical care appear to wait for physicians to initiate these discussions [2]. The entire field might be better served if we took smaller, but regular, steps forward.

A simple question, routinely asked by the physician at the time of initial patient evaluation during the history and physical examination, could provide a bridge to the broad and comprehensive planning that is recommended. The physician could ask, "If, for some reason you are unable to make decisions about your medical care or to make your wishes known, whom do you want to speak and decide for you?"

The response to this question would be documented in the patient's record and could serve as an informal advance directive [3]. Patients would be asked to inform their designated proxy and to discuss their wishes and concerns with that person. On subsequent visits, extensions of the modest initial question could lead to broader planning with completion of written, individualized advance care plans. The question would be asked of all competent patients at the various points of entry to medical care. A mechanism to designate proxies for persons who cannot make decisions or for competent patients who do not have trusted family members of friends would supplement this approach.

As the Chinese proverb states, a journey of a thousand miles must begin with a single step. Asking "the question" may be a minimally burdensome beginning for the longer journey.