Adherence to advance directives

Editor—Those of us who have made advance directives can only be dismayed and concerned by Thompson et al's assumption that there will always be ambiguity.¹ Firstly, doctors can strangely assume that patients might aspire to spend their last days demented in a residential home. Secondly, this assumption is enough to justify giving an antibiotic to prolong everyone's agony, mainly that of the patient.

Prescribing an antibiotic is the easy option; many of us have done it. I will always remember the withering look coupled with the remark “Why did you do it?”of a most distinguished, very elderly lady to whom I administered a parenteral antibiotic when she was delirious with pneumonia. She recovered and eventually developed dementia. There was no alternative to the antibiotic: there was no advance directive. Higgs commented in the BMJ that pneumonia, the old person's friend, may be dismissed with a wave of the prescribing pen—but what if the old person wishes the friend to call?²

What can be done to counteract the ambiguity? The hypothetical advance directive, although apparently fully comprehensive and perhaps thought to be irrefutable, should additionally include:

• A statement of general beliefs and aspects of life that the person values. My own statement is long and detailed and includes the hope that I will not end up a burden to my carers, and that I will not have inflicted on me a meaningless struggle against unacceptable mental or physical disability by my doctors

• A statement naming a proxy who would help the doctors with interpreting the advance directive.

If my directive with these additions is still ignored I hope that my relatives would not hesitate to sue for assault or negligence.