The problem with advance directives: Maybe it is the medium, not the message

Abstract

Some of today's most significant bioethical challenges center around decisions to initiate or withhold medical treatment for incapacitated patients. In order to ascertain what treatment the patient would have desired, physicians often rely on written advance directives and designated surrogate decision-makers. Unfortunately, both approaches suffer from numerous shortcomings that ultimately limit their usefulness. Although several strategies have been proposed to improve their value, problems nevertheless remain when relying upon written advance directives. We submit that the problem is the medium, not the message—that written advance directives and/or reliance on surrogate decision-makers are fundamentally inadequate. We hypothesize that videotaped advance directives (VADs) can better communicate the specifics, depth, strength and passion of a patient's wishes, more closely approximating the communication that occurs when a physician discusses these issues directly with a patient. VADs may thus enhance the physician's understanding of the patient's wishes. VADs may also ease family conflict and save physician's considerable time by helping family members reach a stronger consensus on the patient's wishes, and do so in a timelier manner. This article reviews the limitations of written advance directives and surrogate decision-makers and describes why VADs may be helpful in overcoming these limitations.