Awareness of living wills in the United Kingdom

SIR—We read with interest the results of questionnaire survey of British geriatricians regarding ‘Living wills and the Mental Capacity Act’ by Schiff et al. [1]. It is good to know that geriatricians favoured the use of living wills and that many had come across living wills while caring patients and felt it helped in end-of-life care planning. We too feel that people in the United Kingdom have less experience of living wills than those in the United States. Schiff et al. interviewed 74 London inpatients (mean age 81) in 2000. More than three-quarters had not heard of living wills. In 2001, another study involving 56 London inpatients (mean age 77), 11 had heard of living wills but only one had executed such a will [2]. In contrast, a study in 1992 involving 214 American individuals (aged 65–91 years) found that 32 had written a living will and two-thirds of remaining respondents planned to do so [3]. The reason behind this may reflect difference in legal requirements. In the United States, under the Patient Self Determination Act, every individual has a statutory right to accept or refuse medical care and to execute a written advance directive [3]. In Britain, there is no such legal requirement. Wide variations have been noted in studies regarding the agreement between surrogate and patient, and in some, it is no better than mere chance [1]. Doctors are not always skilled in anticipating the wishes of their patients. A patient’s health beliefs are important in determining the choice of treatment, and older people use very individualistic health beliefs in judging how to trade risks with preserving quality of life [4]. This is now particularly relevant in view of the shift of emphasis from physicians’ benign paternalism to patient autonomy. Living wills can promote patient autonomy. We suggest that doctors should routinely take an ethics history, ideally, when patients are not seriously ill [5]. This focuses on living wills and the power of attorney as well as on views on artificial feeding, major surgery, ventilation, cardiopulmonary resuscitation, organ donation, communication with and decision-making by family members. Patients did not feel stressed when such issues were discussed with them in a previous study [2]. Spending a few minutes on these subjects when the patient is relatively well is preferable to trying to gauge their best interests during medical crises.