Intended for healthcare professionals


Decisions to withdraw treatment

BMJ 2000; 320 doi: (Published 01 January 2000) Cite this as: BMJ 2000;320:54

Values histories are more useful than advance directives

  1. Chris Docker, director (
  1. Voluntary Euthanasia Society of Scotland, Edinburgh EH1 3RN
  2. Middlemore Hospital, Auckland, New Zealand
  3. Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children, London WC1N 3JH
  4. Heatherwood Hospital, Ascot SL5 8AA

    EDITOR—Winter and Cohen recognise one of the problems with advance directives when they correctly state: “The advance refusal of treatment is legally binding provided certain conditions are met…. A problem still exists unless they are precisely worded.”1

    Traditional advance directives are becoming less and less useful, partly as a result of lack of data on when treatment becomes futile in different clinical scenarios. When advance directives were first introduced, the application of standard “heroic measures,” often without reasonable expectation of result, was far more common than it is today. In that situation, a general advance directive about refusing, say, cardiopulmonary resuscitation, was an appropriate statement of common sense. The situations facing modern intensive care units are far more complex. The tendency towards precise wording in advance directives to make them legally binding has made it difficult for them to keep up with the pace of medical technology.2

    An alternative approach that is finding increasing favour, either as an adjunct to the advance directive or as a stand alone instrument, is the “values history.” Values histories relate to the declarant's values rather than instructions. Patients' values are recorded as a basis for decisions on medical treatment (rather than including explicit instructions on specific treatments). They identify core values and beliefs in the context of terminal care that are important to the patient. 3 4

    Values histories take a goal based rather than prescriptive approach, giving guidance on a policy to be implemented rather than the medical means to the end. The legal persuasiveness of them is less strong, but they may be useful adjuncts when a person is seeking to …

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