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Edmund D. Pellegrino, MD
JAMA. 1992;268(3):354-355. doi:10.1001/jama.1992.03490030066030.
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The Patient Self-determination Act, which took effect in December 1991, is designed to alert patients to their right to execute advance directives that will guide treatment decisions should they become incompetent.1 This review summarizes some of the complex and unresolved ethical issues that should concern physicians and hospitals as they implement the new law.

The Patient Self-determination Act does not require that patients have advance directives.2-4 Rather, it requires health care institutions to provide written information informing patients of their legal rights under state law to make advance directives. Institutions must now document any advance directive a patient may have executed but must not discriminate in the care provided on the basis of the existence or nonexistence of a directive. They must also maintain written policies and procedures regarding advance directives and provide staff and community education workers with this knowledge.

Advance directives are of two types: (1)


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