January 1992

Advancing the Cause of Advance Directives

Author Affiliations

Centre for Bioethics University of Toronto Tanz Neuroscience Bldg, Room 303 6 Queen's Park Crescent W Toronto, Ontario Canada M5S 1A8; Center for Clinical Medical Ethics University of Chicago Chicago, IL 60637 Dr Singer is supported by a medical scholarship from the Canadian Life and Health Insurance Association, Toronto, Ontario. The Centre for Bioethics is supported by a Health Systems—Linked Research Unit Grant from the Ontario Ministry of Health, and by the Bertha Rosenstadt and William C. Harris Estates, Toronto, Ontario. The Center for Clinical Medical Ethics is supported by the Henry J. Kaiser Family Foundation, Menlo Park, Calif, the Andrew W. Mellon Foundation, New York, NY, and the Pew Charitable Trusts, Philadelphia, Pa. The opinions expressed herein are those of the authors and may not represent those of the supporting groups.

Arch Intern Med. 1992;152(1):22-24. doi:10.1001/archinte.1992.00400130048002

The case of Nancy Cruzan has been described, discussed, and analyzed in the medical literature,1-12 most recently in this issue of the Archives by Fairman.13 We concur with Fairman's conclusion, shared by most commentators, that the Cruzan case will encourage the use of advance directives. An advance directive is a written document completed by a competent person that aims to guide medical treatment after the person becomes incompetent.14 There are two types: instruction directives, which focus on the types of life-sustaining treatment that the person would want under various clinical situations, and proxy directives, which focus on who the person would want to make health care decisions if the person were unable to do so. To successfully incorporate advance directives into North American health care systems, however, four challenges require serious attention. This editorial will describe these challenges in research, education, substitute decision making, and patient demands for

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