End-of-Life Care Issues

A Personal, Economic, Public Policy, and Public Health Crisis

Dan K. Morhaim, MD; Keshia M. Pollack, PhD, MPH


Am J Public Health. 2013;103(6):e8-e10. 

In This Article

Abstract and Introduction


Advance directive documents are free, legal, and readily available, yet too few Americans have completed one. Initiating discussions about death is challenging, but progress in medical technology, which leads to increasingly complex medical care choices, makes this imperative.
Advance directives help manage decision-making during medical crises and end-of-life care. They allow personalized care according to individual values and a likely reduction in end-of-life health care costs.
We argue that advance directives should be part of the public health policy agenda and health reform.


Is end-of-life care a matter of personal values, economics, public policy, or a looming public health crisis? Actually, it is all of these. But when we consider the population's demographic shift to older adults, which is associated with chronic illness and multiple comorbidities, the enormous health care costs consumed in end-of-life care, and complex ethical issues, it is time for the public health community to put this issue squarely on its agenda. Increasing the rate of completion of advance directives is a key step, and specific policy strategies can be identified to accomplish this objective.

Advance directives were created by federal and state law to ensure autonomy of patients who eventually become unable to make decisions for themselves.[1,2] Advance directives are free, legal, and straightforward forms that can be completed in a few minutes. Typically, advance directives address several areas regarding endof- life care when a person becomes unable to make medical decisions for himself or herself. First, a person defines the amount and kind of care he or she might receive under various medical circumstances. Second, a person designates a health care agent to make medical decisions when the person can no longer do so. Third, advance directives may also address other end-of-life care issues including organ donation, whole body donation to medical schools, funeral and burial arrangements, legacy recordings for posterity, and—in 3 states (Oregon, Washington, and Montana)—assisted dying.