Advance Directives: Time To Move On

There is always an easy solution to every human problem—neat, plausible, and wrong.

–H.L. Mencken (1)

For the past 2 decades, people have debated the role of advance directives in decision making and improving end-of-life care in the United States (2-4). From a normative standpoint, advance directives are an important legal tool for persons to state preferences and name a surrogate decision maker in case they became mentally incapacitated later in life. However, empirical research findings raise questions about the role of written advance directives because of doubts about the stability of patient preferences (5), how living wills are used in decision making (6), and the role of living wills in reducing health care costs (7, 8). In this issue, Degenholtz and colleagues (9) report results from a secondary analysis of Asset and Health Dynamics Among the Oldest Old (AHEAD) study data. They found that the completion of living wills was associated with a lower rate of in-hospital deaths. On the basis of these results, the authors question the validity of previous studies that did not show an effect on the rate of in-hospital deaths. They claim that previous studies suffer from selection bias because they examined the role of advance directives only in patients in acute care hospitals.

The …