Advancing the Cause of Advance Directives

The case of Nancy Cruzan has been described, discussed, and analyzed in the medical literature,1-12most recently in this issue of theArchivesby Fairman.13We concur with Fairman's conclusion, shared by most commentators, that the Cruzan case will encourage the use of advance directives. Anadvance directiveis 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