ABSTRACT
The availability of resources in the United States has made the provision of life-sustaining treatments and life-saving surgeries available even for patients in the old and very old age groups. The combination of available resources and a cultural focus on autonomy results in some older individuals spending their final days receiving prolonged intensive care aimed at a tiny chance of recovery. The federal Patient Self-Determination Act in 1990 required health-care providers to inform patients of their rights to make health-care decisions and to execute advance directives. Advance-care planning is carried out through conversations with patients. Theoretically, this would best be accomplished within the context of a continuous clinical relationship during a time of clinical stability. Many factors conspire against the success of advance-care planning, including inadequate physician education, the time needed to carry out the task, Americans' discomfort with death and desires not to discuss end-of-life issues, and concerns about the validity of prior decisions to direct later care.
