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Paper Chase

The Medical Directive. A new comprehensive advance care document.

JAMA. Jun 09, 1989;261(22):3288-93.
Emanuel LL, Emanuel EJ.

General Internal Medicine Unit, Massachusetts General Hospital, Boston, MA 02114.


Living wills have been strongly endorsed in principle. Unfortunately, existing living wills are rarely used in clinical practice because they are vague and difficult to apply. To remedy this, we propose a new advance care document: the Medical Directive. The Medical Directive delineates four paradigmatic scenarios, defined by prognosis and disability of incompetent patients. In each scenario, patients are to indicate their preferences regarding specific life-sustaining interventions. The Medical Directive also provides for the designation of a proxy to make decisions in circumstances where the patient's preferences are uncertain. Finally, there is a section for a statement of wishes regarding organ donation. The Medical Directive provides an opportunity for significant improvement in the documentation of patients' preferences regarding life-sustaining care in states of incompetence. As an expression of a patient's wishes, the Medical Directive should be honored by courts and should facilitate physician-patient discussions of critical and terminal care options.

Living wills have been endorsed in principle but little used in practice because physicians and patients find them vague and difficult to apply. The authors propose a new advance care document, the Medical Directive, that physicians can recommend to promote the inclusion of patient preferences in medical decisions at the end of life. A Medical Directive is divided into five parts: an introduction, a section of five paradigmatic scenarios of illness in which preferences for treatment are given, a section for the designation of a proxy decision maker, a section for organ donation, and a personal statement of the patient's goals and values. Possible objections to the Medical Directive are answered by the authors, who recommend routine availability and discussion of the Directive.