Patients and their families struggle with myriad choices concerning
medical treatments that frequently precede death. Advance directives have
been proposed as a tool to facilitate end-of-life decision making, yet frequently
fail to achieve this goal. In the context of the case of a man with metastatic
cancer for whom an advance directive was unable to prevent a traumatic death,
I review the challenges in creating and implementing advance directives, discuss
factors that can affect clear decision making; including trust, uncertainty,
emotion, hope, and the presence of multiple medical providers; and offer practical
suggestions for physicians. Advance care planning remains a useful tool for
approaching conversations with patients about the end of life. However, such
planning should occur within a framework that emphasizes responding to patient
and family emotions and focuses more on goals for care and less on specific
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