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Decisions regarding life-sustaining treatment for incompetent patients are typically difficult and stressful for surrogate or proxy decision makers. Although substituted judgment and best interest provisions are helpful to next of kin or guardian and help replicate an incapacitated patient's wishes, a more definitive expression of treatment preferences is needed. Advance directives allow currently competent persons to express their wishes about medical treatment before a possible incapacitating situation. Such directives seek to realize basic values of human dignity, respect for self-determination and human life, and communication and discussion with the person concerning treatment. Three types of directives are the living will or instruction directive, proxy directive or durable power of attorney, and a combination of the two. Legislative concerns over advance directives mainly focus on possible legal euthanasia, patient protection, ambiguous language, and other inadequacies. Catholic healthcare facilities can respond to concerns about advance directives in four positive ways: Make information about directives available to patients and providers. Contribute to constructive debate in states without legislation. Include provisions for proxy decision making in states with existing patients' bill of rights. Consider legislation to protect physicians from litigation when patients' written directives are followed.

In response to widespread physician noncompliance with "do not resuscitate" (DNR) guidelines in 1983, the ethics committee at St. Joseph's Hospital, St. Paul, MN, set out to clarify the confusion over "supportive care only" (SCO) and DNR orders. A task force of nurses and physicians developed tentative supportive care guidelines and a subcommittee related ethical principles to the supportive care concept. The completed draft, "Principles and Guidelines in Deciding to Forego Life-Sustaining Treatment," was reviewed by the medical executive board and hospital attorney. St. Joseph's medical staff and board of trustees approved it in May 1985, and the document became hospital policy. The policy addresses patient autonomy, the burden/benefit principle, informed consent, and patient competency. It lists six guidelines for making supportive care plans. St. Joseph's has implemented the policy in several ways. Committee members make "ethics rounds" to discuss patient cases and the guidelines with hospital personnel. A brochure acquaints patients and their families as well as community groups with the guidelines. Nurses have introduced the guidelines to physicians in critical care units. When necessary, new insights will be incorporated into the guidelines.