Implementing advance directives in office practice.

Patients prepare advance directives in an effort to maintain autonomy during periods of incapacity or at the end of life. Advance directive documents are specific to the state in which the patient lives, but an effective strategy in the family physician's office involves more than filling out a form. Physician barriers to completing an advance directive include lack of time and discomfort with the topic. On the patient's part, lack of knowledge, fear of burdening family, and a desire to have the physician initiate the discussion are common barriers. Once the advance directive is complete, barriers to implementation include vague language, issues with the proxy decision maker, and accessibility of the advance directive. Overcoming these barriers depends on effective communication at multiple visits, including allowing the patient the opportunity to ask questions. Involving the family or a proxy early and over time can help the process. It may be helpful to integrate advance directive discussions at selected stages of the patient's life and as health status changes.