After the protracted 15-year Florida legal case of Terri Schiavo concluded in 2005 (discussed in this chapter's fourth section), most Americans have heard about advance directives (i.e., living wills and durable powers of attorney for health care), and most (hopefully) now have also learned the valuable lesson that an oral expression for future care may not lead to the intended consequence. This chapter focuses the reader's attention on using written preventive ethics tools in geriatric practice in planning for end-of-life care. This chapter first examines the legal development and ethical significance of the living will and durable powers of attorney for health care, then examines some of the ethical conflicts that can be associated with the use of written advance directives, and considers a stepwise preventive ethics approach to these advance directives in clinical practice.

THE BEGINNINGS OF ADVANCE DIRECTIVES

Although the concept of living wills began in the 1960s, the legal beginnings of what we now call “advance directives” arose from a grassroots response to In Re Quinlan, decided by the New Jersey Supreme Court in 1976. Ms. Quinlan, a 21-year-old woman, suffered two prolonged anoxic episodes of unknown origin, was resuscitated by a rescue team, hospitalized, and subsequently was in a persistent vegetative state (PVS). Her father petitioned the court for guardianship of her person for the purpose of requesting that respirator support be discontinued, with the understanding that the higher probability was that his daughter would die.