Because some states regard oral advance directives as untrustworthy, written advance directives have several advantages. Living wills generally are limited to the refusal of interventions that would only prolong the process of dying. Some states explicitly exclude intravenous fluids and tube feedings from the interventions that may be refused, although courts might rule that such an exclusion violates patient rights. The surrogate is required to act in accordance with the patient's previously expressed preferences or best interests. Patients can usually indicate specific treatments they would accept or refuse in various situations.
Different states have specific procedures for appointing surrogates.
Some have durable power of attorney for health care or health care proxy laws for the appointment of surrogates, whereas others allow appointments as part of living wills. Physicians need to be familiar with state laws. Physicians should raise the issue of advance directives routinely with competent adult patients in outpatient visits and encourage them to provide advance directives and to discuss their preferences with their surrogate and family members. In addition, the Patient Self-Determination Act of 1990 requires hospitals, nursing homes, health maintenance organizations, and hospices that participate in Medicare and Medicaid programs to provide patients, on admission or enrollment, with information about their right to provide advance directives. These health care institutions are required to respect advance directives to the fullest extent permitted under state law.