March 13, 1995

Why No Advance Directive?

Author Affiliations

Philadelphia, Pa

Arch Intern Med. 1995;155(5):547. doi:10.1001/archinte.1995.00430050127018

In their article, published in the April 15, 1994, issue of the Archives, Brooks et al state that their finding of limited availability of advance directives is "further evidence of a low level of physician involvement in this area."

I think that this is a gross misstatement and it overlooks the whole host of cultural, religious, and personal reasons that influence elderly nursing home residents (and, indeed, community-dwelling elderly) to forego formal statement of their preferences.

In my experience as a medical director of a nursing facility, a founding member of its ethics committee, and a personal physician to about a third of its residents, I have been repeatedly impressed by how often people do not wish to make formal advance directives. It is my practice to discuss this issue on first acquaintance and then, again, about 3 weeks later. Subsequently, the topic will be reintroduced if there is a

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