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American Behavioral Scientist
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The Use of Advance Directives in End-of-life Decision Making

Problems and Possibilities

ANGELA FAGERLIN

University of Michigan VA HSR&D Center for Practice Management & Outcomes Research

PETER H. DITTO

University of California, Irvine

NIKKI AYERS HAWKINS

University of California, Irvine

CARL E. SCHNEIDER

University of Michigan

WILLIAM D. SMUCKER

Summa Health System

Instructional advance directives (i.e., living wills) have been endorsed widely as a crucial method for maintaining seriously ill patients' autonomy at the end of life. Theoretically, living wills maintain the patient's voice in treatment decisions by enhancing the ability of surrogate decision makers to make the treatment choices that patients would make for themselves if competent. For living wills to achieve their goal, the following three assumptions must be met: (a) People must complete living wills, (b) treatment preferences recorded in living wills must be authentic, and (c) surrogate decision makers must be able to interpret living wills and use them to make accurate treatment predictions. The authors review the medical and psychological literatures bearing on these assumptions and find that the available empirical evidence challenges the validity of each assumption. The authors conclude by discussing the potential benefits of advance directive use and directions for future research.

American Behavioral Scientist, Vol. 46, No. 2, 268-283 (2002)
DOI: 10.1177/000276402236678
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