Annals of internal medicine
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Physicians in intensive care units have withdrawn life support in incapacitated patients who lack surrogate decision makers and advance directives, yet little is known about how often this occurs or under what circumstances. ⋯ Incapacitated patients without surrogates accounted for approximately 1 in 20 deaths in intensive care units. Most life-support decisions were made by physicians without institutional or judicial review.
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Advance directives promise patients a say in their future care but actually have had little effect. Many experts blame problems with completion and implementation, but the advance directive concept itself may be fundamentally flawed. Advance directives simply presuppose more control over future care than is realistic. ⋯ Because advance directives offer only limited benefit, advance care planning should emphasize not the completion of directives but the emotional preparation of patients and families for future crises. The existentialist Albert Camus might suggest that physicians should warn patients and families that momentous, unforeseeable decisions lie ahead. Then, when the crisis hits, physicians should provide guidance; should help make decisions despite the inevitable uncertainties; should share responsibility for those decisions; and, above all, should courageously see patients and families through the fearsome experience of dying.