Directives anticipées

This article reviews advance directives (AD) and corresponding worldwide literature. From this comparative analysis and considering the French regulation, the authors highlight limits and prospects to improve AD and their applicability. All national laws aim at protecting patient's autonomy but differ by country. The German experience seems promising and well balanced. In the USA, a series of hierarchical types of AD have been proposed among which POLST (Physician Orders for Life-Sustaining Treatment) may help securing AD and their availability at bedside, especially in case of patient transfer. Repositories for AD may serve the same purpose in an efficient way. Models for AD have been proposed to patients by learned societies to highlight items important to consider which are not straightforward to patients. Documenting these points are mostly important to build AD contextual enough to patient condition. Moreover, a patient value testimony is probably the best way to help AD being considered by caregivers. Choosing a spokesperson with a clear delimitation of what patient expects from or confers to her, as a representative represents another major goal of AD. In addition to the end of life, AD may also encompass the issue of organ donation and the case of a permanent vegetative state. Time limited validity for AD raises difficulties when the case of a vegetative state and locked-in syndrome is considered in full health and the withdrawal of life support therapies is foreseen.