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Understanding Advance Directives as a Component of Advance Care Planning

Walsh (2020) presents an argument against what she calls the received view of advance directives in the philosophical literature, suggesting instead a view that she believes is supported by “real clinical practice.” However, the argument she presents has radically disruptive implications for clinical practice and is greatly at odds with current expert clinical recommendations. For example, Walsh argues for more stringent regulation of advance directives, and goes so far as to suggest that websites that facilitate advance directive completion should be banned. Yet clinicians have argued that onerous legal requirements for advance directives have adverse consequences, particularly for vulnerable patients without access to the legal consultation that Walsh treats as essential (Castillo et al. 2011; Rolnick et al. 2017), and have designed largescale clinical trials to validate the efficacy of advance directive completion websites in diverse populations (Sudore et al. 2018). Walsh also extends her argument in passing to object to advance directives that designate surrogates or powers-of-attorney to decide on patients’ behalf, where expert clinical groups have advocated for such documents as essential components of patients’ care plans (Nuffield Council on Bioethics 2009; Institute of Medicine 2015). While Walsh presents her position as a defense of clinical common sense, there is a chasm between her proposals and clinical best practices (as well as the clinical practice of the second author of this commentary). What accounts for the divergence between Walsh’s skepticism about advance directives and the importance placed on advance directives by clinicians? One problem appears to be Walsh’s antiquated and narrow conception of the role of advance directives in clinical decision-making. Crucially, Walsh does not address the broader concept of advance care planning, of which advance directives are in most cases a critical component (Sudore et al. 2017). Advance care planning, understood as a process, has well-established clinical benefits for patients and families, including: improved communication between family members and clinicians, increased patient and family satisfaction, reduced family member stress and anxiety, and increased use of hospice care (Teno et al. 2007; Silveira et al. 2010; Detering et al. 2010). It is unfortunate that Walsh does not engage with this clinical literature. Several of Walsh’s arguments echo well-known limitations of advance directives in medical decision-making. It can be difficult to prognosticate a patient’s course and make advance decisions for predicted clinical states, and directives that refer too narrowly to specific treatments can fail to leave room for interpretation or to offer guidance about decisions beyond those envisioned. However, clinicians caring for patients with dementia have responded not by discounting the moral weight of advance directives or advocating legal barriers to advance directive completion. Rather, clinicians have adopted a conception of advance care planning focused on better understanding patients’ values and goals of care, to safeguard autonomy and ensure that patients’ wishes are respected in the event that they are unable to make their own care decisions. The goal of such planning is not to rigidly specify care decisions in advance, without regard for how patients’ preferences may be changed in the course of illness. Instead, clinicians have argued for a more inclusive conception that prepares for flexibility and shared decision-making, providing patients with the opportunity to explore their personal