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

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

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University of California, San Francisco, San Francisco Veterans Affairs Medical Center, USA.



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


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


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.


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


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.


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.


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


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.


U.S. Department of Veterans Affairs and the Pfizer Foundation.

[Indexed for MEDLINE]
Free PMC Article

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