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Wednesday, April 7, 2010

Advance Directives

One question that often comes up is why the CCD, or other specifications based upon it only specify what kind of advance directive exists and where to find it, and do not what the content further.  But providers do want to know what's in these things so that they can act appropriately.

When this topic was discussed (in three different venues I might add), three years ago, there was a problems identified with classifying details of an advance directive.  The classification of advance directives depends upon the legal jurisdiction where it is interpreted.  To say any more than "an advance directive with respect to resuscitation status" exists could have patient safety and legal implications that could not be resolved using any existing controlled vocabulary, and it still cannot today.

Many advance directives are are legal documents, and the content of them is often unconstrained.  It could say just about anything you want to in words, and that even when the document has same name (a classification such as a DNR Order), they may have different meanings depending upon the state in which you live or are recieving care.

As a consequence, the CCD and specifications from IHE and HITSP which derive from it do not specify what appears within an advance directive.  The advice given to the developers of CCD, based on policies and procedures in force at many institutions, was to alert the provider of the existence of these documents, and to provide references to where they could obtain the content, so as to comply with what the advance directive itself says, and not based on a shorthand assessment and classification of its content.


  1. In filling advance directives there are ethical issues that should be considered. It is important to seek help from a professional lawyer. I appreciate you mentioning that the classification of advance directives depends upon the legal jurisdiction where it is being interpreted. My friend Susy went under the knife last year because she was bleeding profusely. Luckily for her, a couple of years before she had the operation, she consulted a law firm in Ottawa. They gave her legal advice regarding health care. The estate lawyers in Ottawa also explained to her the risks and benefits involved in signing the documents. Good thing she survived the operation. I want to sign a health care proxy someday so I'll have a heart to heart talk with my wife first. Thanks so much for the great post!

  2. Mike and anyone else reading this post, I always advise anyone dealing with legal documents to be sure they understand what they are doing before signing anything. That may require obtaining professional legal advice, or it may not, depending on the individual. There are a number of excellent web sites that can provide assistance. One of my favorites is Five Wishes. For $5.00 an individual copy, you can create an Advance Directives document that works in 42 states in the US, and is very easy for a layman to read and understand.

  3. @keith: Thank you so much for your advise. I agree that before signing a legal document, everything should be clear and thoroughly understood. By the way, I have seen the site that you recommended and you are right - it is very comprehensive. Again, thanks.