Intended for healthcare professionals

Clinical Review ABC of intensive care

Withdrawal of treatment

BMJ 1999; 319 doi: (Published 31 July 1999) Cite this as: BMJ 1999;319:306

Problems with advance refusals

Winter and Cohen in their article 'ABC of intensive care - Withdrawal of Treatment' (BMJ 319 306-308) 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.'

The introduction to their coverage of advance directives ('When to withdraw treatment') perhaps targets why traditional advance directives are less and less useful when they say 'These decisions remain difficult because of the paucity of data on 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, CPR, 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 difficulty keeping up with the pace of medical technology.

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. The expression of a patient’s values are provided as a basis on which medical treatment decisions can be based (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. 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 have an advance refusal respected, or they may provide valuable guidance in their own right.

I would suggest that, in general, the trend towards greater use of values in advance statements is more valuable to patients and intensive care doctors than is the trend towards increasingly specific wording of treatments to be refused, and that the former trend is to be encouraged.

Further details on values histories may be obtained from the Living Will and Values History Project, BM 718, London WC1N 3XX.


Chris Docker
M.Phil, Law & Ethics in Medicine

Docker, C, 'Living Wills / Advance Directives' in: "Contemporary Issues
in Law, Medicine & Ethics" (1996, McLean S. ed.)

Docker C, 'Living Wills' in: "Finance & Law for the ELderly Client"
(forthcoming, 2000, Butterworths Tolley)

Brett A. Limitations of Listing Specific Medical Interventions in Advance
Directives. Journal of the American Medical Association 1991; 266(6):

Doukas D, Gorenflo D. Analyzing the Values History: An Evaluation of
Patient Medical Values and Advance Directives. Journal of Clinical Ethics
(1993) 4(1):41-45.

Doukas D, McCullough L. The Values History - The Evaluation of the
Patient's Values and Advance Directives. Journal of Family Practice 1991;

Gibson J. (1990), 'Values History Focuses on Life and Death Decisions',
Medical Ethics, 5(1):1-2+17.
- Gibson J (1990), 'National Values History Project', Generations, Vol.14

Gibson J. Reflecting on Values. Ohio State Law Journal (1990)

Hoffman M. Use of Advance Directives: A Social Work Perspective on the
Myth Versus the Reality. Death Studies 1994, 18:229-241.

Kielstein R, Sass H. Using Stories to Assess Values and Establish Medical
Directives. Kennedy Institute of Ethics Journal 1993, 3(3):303-325.

Lambert P, Gibson J, Nathanson P. The Values History: An Innovation in
Surrogate Medical Decision-Making. Law, Medicine & Health Care 1990,

Competing interests: No competing interests

20 August 1999
Chris Docker
Voluntary Euthanasia Society of Scotland