• Patricia A Mayer, Bryn Esplin, Christopher J Burant, Brigid M Wilson, MaryAnn Lamont Krall, Barbara J Daly, and Jason Gatliff.
• 1 Cleveland Fellowship in Advanced Bioethics, Cleveland, OH, USA.
• Am J Hosp Palliat Care. 2017 Mar 1; 34 (2): 160-165.

BackgroundAdvance directives (ADs) have traditionally been viewed as clear instructions for implementing patient wishes at times of compromised decision-making capacity (DMC). However, whether individuals prefer ADs to be strictly followed or to serve as general guidelines has not been studied. The Veterans Administration's Advance Directive Durable Power of Attorney for Health Care and Living Will (VA AD) provides patients the opportunity to indicate specific treatment preferences and to indicate how strictly the directive is to be followed.ObjectiveTo describe preferences for life-sustaining treatments (LSTs) in various illness conditions as well as instructions for the use of VA ADs.Design/SettingA descriptive study was performed collecting data from all ADs entered into the medical record at 1 VA Medical Center between January and June 2014.MeasurementsResponses to VA AD with emphasis on health care agents (HCAs) and LW responses.ResultsVeterans were more likely to reject LST when death was imminent (74.6%), when in a coma (71.1%), if they had brain damage (70.6%), or were ventilator dependent (70.4%). A majority (67.4%) of veterans preferred the document to be followed generally rather than strictly. Veterans were more likely to want VA ADs to serve as a general guide when a spouse was named HCA.ConclusionMost of the sampled veterans rejected LST except under conditions of permanent disability. A majority intend VA ADs to serve as general guidelines rather than strict, binding instructions. These findings have significant implications for surrogate decision making and the use of ADs more generally.

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