What Is Really Scaring Americans About Advance Directives?

Cheryl Clark, for HealthLeaders Media , August 19, 2009

So I called Laurel Herbst, MD, an internist who has supervised the dying wishes and death processes for thousands of patients for the last 31 years. What does she think is going on? Why are so many people so upset about advance directives?

"It's superstition," she quickly replies. "Some people believe that if you talk about death, that will make it happen faster."

Herbst, vice president of the Institute for Palliative Medicine at San Diego Hospice, says that for the most part, families and spouses "don't like to talk about values. About what's most important to them. They don't communicate very well at all."

That's why this legislation is so important. It would establish a provision in law that sets up a process to nudge these conversations between caregivers, families and patients, conversations that aren't, for the most part, happening today.

Herbst surprised me by saying that today, because of a basic lack of communication, even advance directives that do exist don't work that well because they're often old, forgotten, lost, ignored or disputed.

"We don't believe that signing an advance directive works very well today, even for people who have them. Because people don't know about them, or the families don't agree with what the patient wanted," she says.

Sometimes, they're even ignored by the caregivers who want to keep treating the patients, because they don't want to be perceived as failing to save the patient.

What is important, she says, is for patients to have those conversations with loved ones and caregivers so everyone is on the same page about how aggressively providers should be to safeguard quality in those oh so very precious last moments of life. "They need to express what's important to them," whether it's to not be connected to machines, or to die at home.

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