Advance Directive and End-of-Life Care

Date of Award


Degree Type


Degree Name

Doctor of Philosophy (PhD)



First Advisor

Sherry Hartman

Advisor Department



The purpose of the Patient Self-Determination Act (PSDA) (1991) was to empower patients to make autonomous decisions in regard to life prolonging interventions used at the end of life by allowing patients to set their own agenda during the dying process based on personal values, beliefs, and goals through advance directives (ADs). This dissertation will examine the effect of advance directives on end-of-life care appropriately ten years since the PSDA. A retrospective study involving 405 medical records of patients who died during the period from January 01, 2000 through March 30, 2004 were reviewed using the researcher developed Advance Directive Study Chart Review Checklist. The major variables examined were the presence or absence of advance directives (living will, treatment preferences, and durable power of attorney for healthcare), adherence to patients' wishes by providers, and factors influencing institutional non-adherence to patients' final wishes. Only 171 patients had advance directives. Of these, 58.1% were progress notes, 14.5% were durable power of attorney for healthcare, and 13.7% were living wills. Only 30 (12.8%) indicated treatment preferences. Most ADs (86.5%) were initiated in the hospital. The Ads were honored for 141 (82.5%) of the patients. Most advance directives (44.4%) were initiated or reviewed within one month of the patient's death. Organizational policies and procedures play a central role in an institution honoring the wishes/preferences of patients at the end-of-life by establishing guidelines to assist healthcare providers in the ethical decision making process for patients at the end of life. Those advance directives contained in the medical records that were not honored, were changed by family members/surrogates after decisions with health care providers when the prognosis was grim without hope of improvement or meaningful quality of life.