Education And Debate

Making an advance directive

BMJ 1995; 310 doi: (Published 28 January 1995) Cite this as: BMJ 1995;310:236
  1. George S Robertson, consultanta
  1. a Department of Anaesthesia, Aberdeen Royal Infirmary, Aberdeen AB9 2ZB
  • Accepted 7 September 1994

The introduction in Britain of advance directives—which allow a person to state in advance of becoming incompetent that they wish to take part in treatment decisions when no longer mentally competent—has now been advocated by the medical and legal establishments. The practical application of directives relating to health care would be simplified by the adoption of a standard model document together with guidelines summarising the background clinical conditions and any subsequent acute events that may make it appropriate to trigger the use of a directive. As no specific legislation exists, good communication is needed at the various stages between the drafting and implementation of directives if the system of directives is to be successful.

It is now accepted that a patient who is adequately informed and mentally competent has the right to refuse any proposed medical treatment provided that the refusal does not create a hazard to the health of others. An advance directive for health care is a statement, usually in writing, in which a person seeks to extend this right into a future time when he or she may not be fully competent.

Legislation for advance directives (or “living wills”) has existed in the United States since the California Natural Death Act was introduced in 1976, and 47 of the 50 states now have some form of law governing the limitation of treatment near the end of life, usually with specific provision for advance directives.

British position

In contrast, the introduction of advance directives in Britain has been slower and less legalistic. Concerns have been expressed about directives, in particular about their value in enhancing patients' autonomy at a time when “the incompetent person is … quite literally a different person from the person who completed the directive.”1 Some would argue, however, that the risk of becoming a different …

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