Lost in translation: the unintended consequences of advance directive law on clinical care

Ann Intern Med. 2011 Jan 18;154(2):121-8. doi: 10.7326/0003-4819-154-2-201101180-00012.


Background: Advance directive law may compromise the clinical effectiveness of advance directives.

Purpose: To identify unintended legal consequences of advance directive law that may prevent patients from communicating end-of-life preferences.

Data sources: Advance directive legal statutes for all 50 U.S. states and the District of Columbia and English-language searches of LexisNexis, Westlaw, and MEDLINE from 1966 to August 2010.

Study selection: Two independent reviewers selected 51 advance directive statutes and 20 articles. Three independent legal reviewers selected 105 legal proceedings.

Data extraction: Two reviewers independently assessed data sources and used critical content analysis to determine legal barriers to the clinical effectiveness of advance directives. Disagreements were resolved by consensus.

Data synthesis: Legal and content-related barriers included poor readability (that is, laws in all states were written above a 12th-grade reading level), health care agent or surrogate restrictions (for example, 40 states did not include same-sex or domestic partners as default surrogates), and execution requirements needed to make forms legally valid (for example, 35 states did not allow oral advance directives, and 48 states required witness signatures, a notary public, or both). Vulnerable populations most likely to be affected by these barriers included patients with limited literacy, limited English proficiency, or both who cannot read or execute advance directives; same-sex or domestic partners who may be without legally valid and trusted surrogates; and unbefriended, institutionalized, or homeless patients who may be without witnesses and suitable surrogates.

Limitation: Only appellate-level legal cases were available, which may have excluded relevant cases.

Conclusion: Unintended negative consequences of advance directive legal restrictions may prevent all patients, and particularly vulnerable patients, from making and communicating their end-of-life wishes and having them honored. These restrictions have rendered advance directives less clinically useful. Recommendations include improving readability, allowing oral advance directives, and eliminating witness or notary requirements.

Primary funding source: U.S. Department of Veterans Affairs and the Pfizer Foundation.

Publication types

  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, Non-P.H.S.
  • Review

MeSH terms

  • Advance Directives / legislation & jurisprudence*
  • Communication Barriers*
  • Cultural Diversity
  • Homosexuality
  • Humans
  • Patient Rights*
  • Religion
  • Social Isolation
  • Spouses
  • United States