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. Medical crises cannot be predicted in detail, making most prior instructions difficult to adapt, irrelevant, or even misleading. Furthermore, many proxies either do not know patients' wishes or do not pursue those wishes effectively. Thus, unexpected problems arise often to defeat advance directives, as the case in this paper illustrates. 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.
Flawed in concept and not just use, advance directives provide little control over future care (6, 7, 64). The last-minute objections to comfort care by Mr. Jones's daughter illustrate the many unexpected problems that can defeat advance directives. Thus, I urge deemphasizing advance directives while searching for better approaches to advance care planning. Camus's ideas suggest one approach that stresses honest communication (33, 57, 75); preparation of patients and families for death's harsh and unpredictable reality (7, 66); mutual support; nonformulaic, individualized care; and courageous decision making despite uncertainties. At the end of Camus' The Plague, the main charactera physician named Rieuxreflects on his role throughout the plague epidemic. He realizes that, along with providing care that had to be given "by all who strive ... to be healers," he bore witness to patients' suffering (76). Physicians surely have the duty to fight disease in most circumstances, but physicians always have the still greater duty to see patients and survivors through their suffering and thereby to bear witness to it. Perhaps that greater duty lifts medicine from a mere occupation to a true profession.