Journal ofMedical Ethics 1998;24:328-335

Comparison of patients' and health careprofessionals' attitudes towards advancedirectivesDanielle Blondeau, Pierre Valois, Edward W Keyserlingk, Martin Hebert and Mireille Lavoie UniversitiLaval, Universite du Quebec a Trois-Rivieres, McGill University, Guy and Gilbert, and Universite' Laval, Canadarespectively

AbstractObjectives-This study was designed to identify andcompare the attitudes ofpatients and health careprofessionals towards advance directives. Advancedirectives promote recognition of the patient'sautonomy, letting the individual exercise a certainmeasure of control over life-sustaining care andtreatments in the eventuality of becomingincompetent.Design-Attitudes to advance directives wereevaluated using a 44-item self-reported questionnaire.It yields an overall score as well as five factor scores:autonomy, beneficence, justice, external norms, andthe affective dimension.Setting-Health care institutions in the province ofQuebec, Canada.Survey sample-The sampling consisted of 921subjects: 123 patients, 167 physicians, 340 nurses and291 administrators of health care institutions.Results-Although the general attitude of eachpopulation was favourable to the expression ofautonomy, multivariate analysis of variance(MANOVA) indicated that physicians attached lessimportance to this subscale than did other populations(p < . 001). Above all, they favoured legal externalnorms and beneficence. Physicians andadministrators also attached less importance to theaffective dimension than did patients and nurses.Specifically, physicians' attitudes towards advancedirectives were shown to be less positive than patients'attitudes.Conclusion-More attention should be given to theimportance of adequately informing patients aboutadvance directives because they may not represent anadequate means for patients to assert their autonomy.(7ournal ofMedical Ethics 1998;24:328-335)Keywords: Advance directives; durable power of attorney;living will; professionals' attitudes; bioethics

IntroductionAdvance directives are becoming an increasinglycommon social phenomenon; they are also

becoming a topic that appears in the literature ona regular basis. Directives give individuals anopportunity to exercise a certain measure of con-trol over care and treatment, especially life-sustaining treatments. Directives are drawn up inadvance by a person capable at that point of mak-ing decisions. Specifically, advance directivesexpress the wishes of the individual to be appliedat a time when he or she has become incapable ofmaking decisions.' Over the past few years, thisacknowledgment of patients' right to self-determination has raised awareness of theimportance of informed consent, as well as aboutthe emergence of instruments such as advancedirectives.The two most common types of directives are

living wills and durable powers of attorney. Livingwills generally consist of a document in which alucid person expresses his or her refusal to havelife artificially sustained in the event of a terminalillness. This document may also include "aperson's preferences regarding the use of life-sustaining treatments".2 Durable powers of attor-ney designate a mandatary or proxy who can maketherapeutic decisions for the patient should he orshe become unable to make such decisions. Incurrent practice in both the United States andCanada, there is a trend to set up these directivesand to promote their use. The origin of directivescan be traced back to 1976, when the NaturalDeath Act was passed in California, giving livingwills official legal status. To date, most Americanstates have passed legislation that provides a legalframework for living wills, durable powers ofattorney, or both at the same time.3" In Canada,however, there is as yet no explicit legislation gov-erning living wills, although at the time this paperwas written the province of Ontario had proposedfour bills (74, 108, 109, 110) designed to legalizeadvance directives. Durable powers of attorneyhold legal status in the provinces of Quebec andNova Scotia. The passage of legislation governing

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advance directives does promote their use, whichis becoming more and more widespread.5

Keyserlingk uses the term "second generation"in describing the evolution and scope of thisphenomenon.6 The quantity of literature onadvance directives serves as a broad reflection ofthe interest and enthusiasm they arouse amongresearchers. However, nearly everything that hasbeen written on the topic involves theoreticalanalyses of a philosophical and legal nature, withonly a small percentage of articles reportingempirical research findings. Of the 700 articles onthe subject published up to 1993, only 31 (4%)reported empirical findings. Since 1993, thatfigure has risen to 7.8%, and has remained stable.Research generally takes the form of surveys,which essentially provide descriptions of the phe-nomenon. Among the topics addressed, for exam-ple, are frequency of use and type of directiveschosen, attitudes towards these documents, un-derstanding of these documents, patients' capac-ity when signing directives, the influence of orneed for education programmes, consistency ofchoices made by patients with those made by theirfamily or physician, and so on. Although thisresearch is of undeniable interest, there are fewstudies that enable us to gain a better understand-ing of the nature, usefulness, value and efficacy ofadvance directives.7 In addition, although a slightincrease in the volume of empirical research hasbeen observed,'0 as far as we know none of theresearch is based on a defined theoreticalframework that would provide a foundation forunderstanding this phenomenon.Within this context, an empirical research

project based on a theoretical framework was ini-tiated, with the overall objective of exploring andcomparing the attitudes of health care profession-als and patients towards advance directives. Thisresearch concerns only the province of Quebec inCanada and any comparison with others countriescould be hazardous.

Theoretical frameworkThe theoretical framework for this researchproject was not drawn solely from the field ofbioethics. In fact, the epistemological status of thisscience is not clearly defined, and bioethics offersno theoretical models that can easily be put intooperation. For that reason, frame of reference isinspired not only by philosophical principles butalso by psychosocial theories. Indeed, applied eth-ics proposes philosophical references throughnorms and principles which facilitate the under-standing of attitudes formed, amongst otherthings, from beliefs, values and principles. Also,applied ethics, as opposed to clinical ethics, is

more congruent with psychosocial theories ofattitudes." 12 In fact, these theories favour theputting into operation of constructs derived fromthe principles approach. Beauchamp andChildress" propose four principles (autonomy,beneficence, non-maleficence, and justice) insteadof only one as suggested by monist theories. '"-"' Inshort, the theoretical framework selected arisesfrom an attempt to establish attitudinal models inthe health care field in general, and specifically inthis case, in bioethics.

This model is designed to highlight the natureof beliefs that give rise to attitudes. Behaviours,which are not the subject of this article, resultfrom attitudes. In the case of patients, the behav-iour of interest in this study consists in providingor not providing advance directives; in the case ofhealth care professionals, it involves respecting orfailing to respect those directives.

Beliefs were divided into two categories: ethicalbeliefs, divided into three subscales, and otherbeliefs, divided into two subscales. The first broadcategory of beliefs explicitly includes the followingdimensions: (a) beliefs reflecting autonomy, (b)beliefs reflecting beneficence/non-maleficence,and (c) beliefs reflecting justice. These dimen-sions are in accordance with the studies of severalauthors.'3 17 18 Autonomy is the ability to governoneself, make decisions and exercise freedom ofchoice. For example, a patient may provide adirective that expresses his or her wishes regardinglife-sustaining treatments. Similarly, a health careprofessional may decide to respect a directive,thereby recognizing the patient's autonomy. Be-neficence is defined as the moral obligation to dogood to another person and to act in his or herbest interest, while non-maleficence involves theconcept of "doing no harm". Specifically, the atti-tude that results from this type of belief may leadto failure to respect advance directives. Atherapeutic decision may be based exclusively onobjective clinical assessments, out of concern forbeneficence, thereby contravening the wishesexpressed in an advance directive and overrulingthe patient's autonomy. On the other hand,respecting a directive may be motivated by theidea ofdoing no further harm to the patient, out ofconcern for non-maleficence rather than consid-eration of expressed wishes. Justice is used in thegeneral sense of acknowledging the equality ofhuman beings by eliminating sources of discrimi-nation such as age, prognosis, and current abilityto consent. In other words, whether to respect adirective should not, for example, depend on theage of the signatory. Whatever characteristicsapply to those involved, whether they are con-

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330 Comparison ofpatients'and health care professionals'attitudes towards advance directives

Figure 1 Theoreticalframework

fused, young or old, everyone is entitled to thesame consideration.

Other beliefs, apart from ethics, are classifiedunder the following subscales: (a) beliefs regard-ing advantages and disadvantages associated withthe external norms dimension and (b) beliefsregarding advantages and disadvantages associ-ated with the relationships/affective dimension.External norms refer to standard aspects relatedto the validity of documents such as living willsand durable powers of attorney. This includesopinions from associations that may eventuallyrecommend that directives be respected or notrespected; legal considerations (legal status, lapseof time between signature and application, uncer-tain interpretation, etc), which may motivate fail-ure to respect directives, and administrativepolicies that may, due to economic rationalizationfor example, promote the use of advance direc-tives. The relationships/affective dimension in-volves relationships between the patient, the

caregiving team and the family. For example, aphysician may refuse to comply with the wishesexpressed in an advance directive if the family hasobjections. Affective reasons also include fears,convictions and feelings that arise from theapproach of death. For example, fear of sufferingmay lead a patient to sign an advance directiveindicating a desire for rapid relief of pain.

In summary, the model suggests that anindividual is likely to have a positive attitudetowards advance directives if he or she believesthat the directives promote the expression ofwishes (autonomy) and equity among humanbeings (justice), and that they contribute, forexample, to helping the family cope with the emo-tional burden or reduce the fear associated withthe risks of relentless therapeutic efforts(relationships/affective dimension). An individualis likely to have a negative attitude towardsadvance directives if he or she believes that (a)pursuing the best clinical interests of the patient

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(beneficence) and (b) considerations of anadministrative and legal nature (external norms)should prevail over written wishes.

In the absence of factual data regarding the useof advance directives in Quebec, we felt it impor-tant to explore the underlying attitudes thatdetermine whether or not advance directives aremade. First of all, it was crucial to identify theattitudes of four groups of individuals (physicians,nurses, health care administrators and patients)towards advance directives. Secondly, we wantedto compare the respective attitudes of these popu-lations. Based on the literature and the theoreticalcontext, patients' attitudes towards advance direc-tives are likely to be as positive as the attitudes ofhealth care professionals (physicians, nurses andadministrators). However, the reasons or beliefsthat determine attitudes may vary from group togroup. The objective of this study was therefore toverify differences between health care profession-als and patients based on five subscales thattogether comprise attitude towards advance direc-tives: autonomy, beneficence/non-maleficence,justice, external norms, and relationships/affectivedimension.

MethodSUBJECTSThe sampling of 921 subjects was composed ofpatients, physicians, nurses and administrators(nursing directors, directors of professional serv-ices, and executive directors). The patients (n =123; 42 men and 81 women) were selected fromamongst volunteers who came forward at regionalgeneral meetings and the annual general meetingof patients' committees affiliated with the QuebecProvincial Patients' Committee. The physicianswere recruited through the Professional Corpora-tion of Physicians of Quebec from a stratifiedsampling based on sphere of activities (generalpractitioners and specialists) and specialties likelyto be exposed to the phenomenon of advancedirectives. Out of a total of 690 physicians, 167(24.2%; 117 men and 50 women) participated inthe research project. The nurses were selectedthrough the Quebec Order of Nurses from astratified sampling based on practice setting (forexample, seniors' residences and chronic-carefacilities) and unit (for example, oncology, cardi-ology). Of the 700 nurses who were approached,340 (48.7%; 28 men and 312 women) agreed toparticipate. Hospital administrators throughoutthe province (625) were contacted through theQuebec Order of Nurses and the Quebec Hospi-tal Association. The response rate was 46.7% (n =291; 141 nmen and 150 women). The relativedegree of precision for the physician, nurse, and

administrator samples was 3% with a confidencelevel of 95%. The average ages of patients, physi-cians, nurses and administrators were 64.7, 47.7,39.7 and 47.9 respectively.

QUESTIONNAIREA questionnaire was drawn up to elicit subjects'attitudes towards advance directives. The ques-tionnaire included explanatory notes about vari-ous advance directive forms, as well as sample liv-ing wills and durable powers of attorney. Theliving will is a form on which a person can indicatewhat care (treatment) he would accept or refuseshould he become very ill or, for example, uncon-scious. In the living will, people therefore state,while still competent and in possession of theirfaculties, how they would wish to be treatedshould they become too ill to express their wish.The living will is a declaration made and signed bythe person concerned. It concerns the treatmentand care desired or refused. It provides for a situ-ation where the person would be incapable ofexpressing his or her wishes. The durable power ofattorney designates a person called in Quebec amandatary, who is thereby authorised to makedecisions about care and treatment when thepatient can no longer do so. Decisions are madesolely in the patient's interest and, if possible, takeinto account the wishes expressed by the patient.Another section of the questionnaire, contain-

ing 44 questions, was designed to measure fivesubscales that together comprise the attitude ofsubjects. The items were taken from a preliminaryqualitative study of 43 patients, 12 health careadministrators, 25 nurses and ten physicians.More specifically, open-ended questions wereused to elicit respondents' perceptions of theadvantages and disadvantages associated with theuse of advance directives. Following a contentanalysis and as suggested by Ajzen and Fishbein,"2the most frequently given responses were retainedfor the questionnaire.Of the 44 items retained, seven involved

autonomy, seven beneficence/non-maleficence,seven justice, 13 external norms, and tenrelationship/affective dimensions. For example,the statement: "By signing a form, a person canspare his or her nearest and dearest manyconcerns" came under the subscale ofrelationships/affective dimension. The statement:"No matter what the illness, the wishes expressedin a form should be respected" came under thesubscale of justice. The subjects were asked toshow on a Likert-type six-point scale their level ofagreement (+6) or disagreement (+ 1) with each of44 statements. The questionnaire was tested foraccuracy on 105 subjects. Results revealed that

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332 Comparison ofpatients'and health care professionals'attitudes towards advance directives

Table 1 Percentage andfrequency (in parentheses) for health professionals and patients on descriptive questions

Health professionals

Physicians Nurses Administrators Total PatientsVariables (n=167) (n=340) (n=291) (n=798) (n=123)

Awareness of existence of documents:* Yes 92.8 (155) 94.4 (321) 95.9 (279) 94.6 (755) 54.5 (67)* No 7.2 (12) 5.6 (19) 4.1 (12) 5.4 (43) 45.5 (56)

Belief in legal status of:Durable power of attorney* Yes 73.1 (122) 81.2 (276) 88.3 (257) 82.1 (655) 75.6 (93)* No 26.9 (45) 18.8 (64) 11.7 (34) 17.9 (143) 24.4 (30)

Living will* Yes 53.3 (89) 73.5 (250) 48.8 (142) 60.3 (481) 68.3 (84)* No 46.7 (78) 26.5 (90) 51.2 (149) 39.7 (317) 31.7 (39)

Clinical experience:* Yes 46.7 (78) 34.4 (117) - - -

* No 53.3 (89) 65.6 (223) - - -

Type of document signed:* Durable power of attorney 6.6 (11) 8.5 (29) 17.5 (51) 11.4 (91) 22.0 (27)* Living will 10.8 (18) 4.1 (14) 5.2 (15) 5.9 (47) 11.4 (14)* No document 76.0 (127) 76.5 (265) 71.5 (208) 74.6 (595) 46.3 (57)* Other 0.0 (0) 2.9 (10) 3.4 (10) 2.5 (20) 10.6 (13)* Non response 6.6 (11) 8.0 (27) 2.4 (7) 5.6 (45) 9.7 (12)

the questionnaire has clear psychometric qualities(test-retest reliability = 0.89; internal consistency=0.90). The third section of the questionnaireexplored awareness of the existence of advancedirectives, types of documents signed, designationof mandataries, and clinical experience.

DATA COLLECTIONQuestionnaires for patients were distributed byvolunteers at various meetings with the provincialpatients' committee. Those requiring assistance(for example, the blind, paraplegics, etc) wereoffered support by research professionals ormembers of the committee. Most of the question-naires were collected on site, with a few returnedby mail. Questionnaires were mailed out to physi-cians, nurses and administrators. A reminderletter was automatically sent out five days later.Confidentiality was guaranteed in all cases.

ResultsThe results of this study will be presented in twosections: first of all, the descriptive data; secondly,a test of the research hypothesis.

DESCRIPTIVE DATA

Awareness of the existence and status of advancedirectivesAs shown in table 1, results indicated that most ofthe health care professionals (94.6%) stated thatthey were aware of the existence of advance direc-tives. Amongst patients, awareness of directiveswas significantly lower at 54.5%, X'(l) = 173.3,(p<0.0001). Both professionals and patientsstrongly believed (82.1% and 75.6%) that thedurable power of attorney, called a "mandate" in

Quebec, is a legal document, which is in fact thecase.'9 Most of the respondents also thought thatthe living will was a legal document, although inQuebec it is not in fact expressly recognized assuch by law. This belief is stronger amongst nurses(73.5%) and patients (68.3%) than amongst phy-sicians (53.3%) and health care administrators(48.8%).

Clinical experienceAccording to our findings, 46.7% of the physi-cians and 34.4% of the nurses have previouslytreated patients who have signed directives. How-ever, the frequency of exposure to advance direc-tives since their introduction (in 1986 for livingwills and 1990 for durable powers of attorney) isrelatively low, at five exposures for durable powersof attorney and 6.7 exposures for living willsamongst physicians; 4.1 exposures for durablepowers of attorney and 3.6 exposures for livingwills among nurses.

Types of advance directives provided by respondentsTable 1 shows that 74.6% of professionals and46.3% of patients have not provided advance direc-tives. However, durable powers of attorney doappear to be the most popular category amongstthose documents that have been provided. Nonethe less, only 11.4% of professionals and 22% ofpatients have in fact provided such documents.

Designation of mandataryIn 62.2% of cases, health care professionals desig-nated their spouse as their mandatary; a smallerproportion (10.5%) designated a child. Thefigures are reversed when we look at patients, with

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Figure 2 Significance differences between populations for each subscales (items from the beneficence and external normssubscales were reversed).

a higher proportion (55.6%) designating one oftheir children rather than their spouse (14.8%).Some respondents have themselves been desig-

nated as mandataries. Amongst health careprofessionals, 22.4% are mandataries, designatedby their parents (63.1%) or by their spouse(19.6%). The same scenario is seen amongstpatients, with 17% having been designated asmandataries, by their parents (42.9%) or spouses(28.6%) respectively. In virtually all cases (88%),mandatary and designator did discuss their wishesregarding life-sustaining treatment.

TESTING THE RESEARCH HYPOTHESISAlthough the subjects did, overall, have anextremely positive attitude towards advance direc-tives (average = 5.2 on a 6-point scale), inferentialresults show differences of attitudes amongst thevarious populations. Inasmuch as recent studiesshowed that parametric tests seem perfectlyadequate when a 6-point Likert scale is used,2 andthat the F test is insensitive to violations of theassumption of normal distributions,2' we judged itappropriate to analyse our data with parametrictests such as multivariate analysis of variance

(MANOVA). The Hotelling test revealed thatthere were differences in the subscales of attitudetowards advance directives (taken globally) be-tween physicians, nurses, administrators andpatients, F (15, 2735) = 10.75, (p <0.000 1). Uni-variate analyses of variance (ANOVAs) were thenapplied on each subscale. The results shown infigure 2 indicated that each population wasfavourable to patient autonomy and the principleof justice, although physicians attached lessimportance to these dimensions than other popu-lations (p <0.05). Secondly, physicians and admin-istrators appear to favour beneficence more thannurses and patients (p <0.05). Thirdly, physiciansand administrators attached less importance to theaffective dimension than did nurses and patients.Finally, physicians favoured legal external normsmore than nurses and administrators.

DiscussionThe descriptive findings suggest that health careprofessionals are more aware of the existence ofadvance directives than are patients. However,some confusion clearly remains regarding the per-

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334 Comparison ofpatients'and health care professionals'attitudes towards advance directives

ception of the status of these documents, since astrong majority of respondents wrongly believethat living wills are expressly recognized in law.This statement shows the importance of raisingpublic awareness of the existence of advancedirectives. Information should, however, be tar-geted in such a way as to clarify the nature and realusefulness of advance directives, as well as theirlimitations. In fact, signing a living will does notguarantee that the directive will be respected. Itshould be recognized that there is relatively littleclinical experience in the presence of signatories.The question that remains is: does informationalone increase the use of advance directives, whenstudies22 23 tend to show that information onchanging attitudes towards advance directivesdoes not have much impact? Morrison andcolleagues22 sum this up perfectly:

"Gamble and her colleagues and Emanuel et alfound that despite adequate knowledge aboutadvance directives and support for such docu-ments, only a minority of patients (0% and 18%respectively) had engaged in any form ofplanning".24Our findings validate the research hypothesis thatattitudes towards advance directives may differamong populations of professionals and patients.None the less, the general attitude of all populationsis favourable to advance directives. This finding hasemerged from previous studies of physicians,25-28nurses29 and patients. 0-32 However, our researchdoes constitute an advance in the understanding ofattitudes behind behaviours related to providingand respecting advance directives. It identifies fivesubscales that determine attitude: autonomy,beneficence/non-maleficence, justice, externalnorms and relationships/affective dimension.

In the latter category, for example, fear ofsuffering, the desire to avoid being a burden onthe family or to avoid conflicts between the familymembers are sufficient reasons to sign a directive.The results suggest that relationships betweenfamily, physician and patient must be harmoniousif the wishes of the signatory are to be respected.There are also variations among the target popu-

lations in terms of the components of positive atti-tudes. Although autonomy is the determining vari-able across all groups, physicians do have the lowestscore on this subscale. It therefore seems fair tosuggest that recognition of autonomy may conflictwith physicians' desire for beneficence and applyingtheir professional judgment. This finding is also inline with those ofprevious studies.29 34For example,Danis and colleagues concluded: "Thus, the datasuggest that in caring for incapacitated patients,physicians balance respect for autonomy with other

competing ethical principles in order to make whatthey believe are the wisest decisions".35 Zinbergeven goes so far as to say that advance directivesimpose an additional control that is not useful interms of medical practice, and that they interferewith professional acts, thereby calling the physi-cian's judgment into question.28 The fact remains,however, that recognition of autonomy is the primedetermining factor in positive attitudes across allgroups.The relationship/affective dimension, the sec-

ond component in favourable attitudes to direc-tives, also shows some variation amongst popula-tions in the study. Patients and nurses give thiscomponent a higher importance rating than dophysicians and administrators. The use of direc-tives appears to give patients a feeling of havingsome control over life-sustaining treatments andalso of relieving the family of the responsibility ofhaving to make difficult decisions. Fear of being aburden on the family is documented in theliterature.36 37 The use of a directive may alsochannel certain fears and apprehensions in theface of death, or about the omnipotence oftechnology, which causes patients to fear relent-less therapeutic efforts and amplifies the fear ofdeath. There is reason to wonder, however,whether all the anxiety surrounding their eventualdemise arises exclusively from a certain existentialfear or also from a real fear of abandonnement byhealth care professionals.

It comes as no surprise to see that nurses are asfavourable to the relationship/affective dimensionas their patients. In fact, since they play an explicitrole in protecting and defending the interests ofpatients (ie advocacy), there is reason to believethat they espouse the motivations of their clientele.

Finally, physicians and administrators considerthe relationship/affective dimension as less impor-tant than do groups of patients and nurses. Inaddition, the family's objections to the patient'srequest38 and consensus between physician andfamily are important criteria in determiningwhether advance directives are recognized.28

In summary, despite variations across popula-tions in the study, attitudes towards advancedirectives are positive, and are essentially based onthe recognition and promotion of autonomy,beneficence/non-maleficence, justice, externalnorms and relationship/affective considerations.Our findings illustrate the importance of the fivesubscales that together form attitudes towardsadvance directives. However, the value andrelevance of these presently available instruments,especially in promoting autonomy, would seem towarrant closer examination. In other words, areadvance directives an efficient and useful tech-

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nique in the recognition ofautonomy? If not, whattechniques would enable us better to achieve thatgoal in real terms?

Future studies will need to explore the connec-tions between attitudes and behaviours that play areal role in promoting autonomy. Secondly, futurestudies should seek to establish other techniquesin addition to advance directives that wouldencourage patients to express their wishes regard-ing decisions to be made when death draws near,and would encourage professionals to respectthose wishes.

AcknowledgementThis research was funded by grants from theSocial Sciences and Humanities Research Coun-cil of Canada and the Fonds pour la formation deChercheurs et l'Aide 'a la recherche. We gratefullyacknowledge the data collection and data manage-ment efforts of Mireille Lavoie and MicheleLanquin-Ethier. Correspondence concerning thisarticle should be adressed to Danielle Blondeau,Faculty of Nursing, Universite Laval, PavillonComtois, Quebec, Canada, G1K 7P4. Electronicmail may be sent to Danielle.Blondeau@fsi.ulaval.ca

Danielle Blondeau, PhD, is Professor Titulaire in theFaculty of Nursing at Universite Laval, Quebec,Canada. Pierre Valois, PhD, is Associate Professor inthe Department of Education Sciences at the Univer-site du Quebec a Trois-Rivieres, Canada. Edward WKeyserlingk, PhD, is Associate Professor in the Facultyof Medicine, McGill University, Canada. MartinHebert, AA, is a Lawyer at the law firm of Guy andGilbert, Montreal, Canada, and Mireille Lavoie,MSc, is a Professional Researcher in the Faculty ofNursing, Universite Laval, Canada.

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islating advance directives. Health Law in Canada 1992;12:73-89.

2 Advance Directives Seminar Group, Centre for Bioethics, Uni-versity of Toronto. Advance directives: are they an advance?Canadian Medical Association Journal 1992;146: 127-34. (Thequotation is from page 127.)

3 Annas GJ. The health care proxy and the living will. New Eng-land Journal ofMedicine 199 1;324:1210-3.

4 Cranford RE. Advance directives: The United States experi-ence. Humane Medicine 1993; 9:64-9.

5 A decision worth noting is that of the Ontario Court of Appealin Malette v Shulman (1990). Georgette Malette was involvedin an automobile collision. Suffering serious injury, she wasbrought to a hospital emergency room. In her purse, she had aJehovah's Witness card, specifically refusing blood transfusionin any circumstances. She was unconscious and bleedingprofusely. To save her life, Dr Shulman decided to do a bloodtransfusion, overriding Mrs Malette's advance directive. Aftershe had recovered, she sued Dr Shulman. The court held thatDr Shulman was wrong to override Mrs Malette's directive andordered him to pay $20, 000 for assault. This decision upholdsthe validity of a written advance directive and the obligation torespect the wishes expressed by the patient.

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31 Emanuel LL, Barry MJ, Stoeckle JD, Ettelson LM, EmanuelEJ. Advance directives for medical care - a case for greater use.New England Journal ofMedicine 1991;324:889-95.

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34 Danis M, Southerland L, Garrett JM, Smith JL, Hielema F etal. A prospective study of advance directives for life-sustainingcare. New England Jtournal ofMedicine 1991 ;324:882-8.

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37 Doukas DJ, Gorenflo DW. Analysing the values history: anevaluation of patient medical values and advance directives.Jtournal of Clinical Ethics 1993;4:41-5.

38 Hughes DL, Singer PA. Family physicians' attitudes towardadvance directives. Canadian Medical Association Journal 1992;146:1937-44.

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