Use of Advance Directives
In all the cases cited earlier, the courts have endorsed the use of patients’ previously stated wishes regarding life support and the validity of patient proxies in articulating these wishes or deciding for the patients when their wishes are not known. In parallel with these judicial actions, private individuals have chosen to communicate their wishes through living wills. These documents, which may be classified as instructional directives, are least effective when their language is vague and they are applied to patients with uncertain prognoses. Nevertheless, living wills can add greatly in clinical decision making. Unfortunately, the documents are of dubious legal reliability when not legislated by the respective state; in Florida, the first State Appellate Court to review the issue of living wills in, In the Matter of Francis Landy (1983), ruled that a living will that was not approved by the state legislature cannot be the basis for withholding or withdrawing life support.

The California Natural Death Act Directive (1976) is another kind of instructional directive that emphasizes the importance of patient preferences. According to this legislation, persons over 18 years of age who are mentally competent can sign a directive at least 14 days after they have been declared by at least two physicians to be terminally ill, that is, likely to die within two weeks. Two persons who are unrelated to the declarant, who have no interest in his or her estate, and who are not medical providers, are required to witness the declaration, which can be revoked at any time. Although health care workers following the directive are protected from prosecution, they are not punished if they ignore it, so the directive does not guarantee a patient the right to die. Furthermore, few patients can meet the acts eligibility requirements, limiting its usefulness as a way of stating for the record that life support is not desired.
More useful than these and other instructional directives are proxy directives that empower other persons to decide medical issues for patients in a flexible fashion. One such directive, the California Durable Power of Attorney for Health Care (1984), provides that a competent adult may appoint an “attorney-in-fact” to make decisions if he or she becomes incapable of understanding medical options and give informed consent. The attorney-in-fact can be any California adult, including the patients heir, but cannot be his physician. The attorney-in-fact cannot consent to certain procedures such as electro-convulsive therapy or placement in a mental health facility and otherwise must act consistently with the patients written or verbalized wishes. Physicians following the attorney-in-facts decisions regarding withholding or withdrawal of life support cannot be held liable if they do so in good faith. The durable power of attorney has been used by many patients in California and is the model for legislation being drawn up elsewhere.