Endstage Decisions: Health Directives in Law and Practice

Medical decisions toward the end of life can be crucial and difficult for patients, doctors, and families. Law and medicine have been struggling to find ways to strike a balance between what the patients might want (or say they want), and what makes medical, economic, and ethical sense.

One standard is the “Advanced Health Care Directive” (Directive), which guides doctors and surrogates (usually a family member) on what to do when faced with end-of-life dilemmas. Another form, adopted in just over half the states (including California) is the POLST (Physician Orders for Life-Sustaining Treatment). The two types are supposed to complement each other, but they are different in important ways. The Advanced Health Care Directive expresses what a person wants and/or appoints a surrogate in case the patient is unable to express her wishes. Anybody can fill out a Directive, at any time of life. Ideally, a copy goes to the surrogate, if one is appointed, and another to the primary care physician. The POLST form is meant for people who are seriously ill. The Directive (for example “no artificial nutrition by tube”) is supposed to be controlling; the patient, of course, can change her mind; but there is no surrogate. It is an agreement between the patient and the doctor.

Who uses these different forms? How effective are they? To what extent and in what situations are they useful? Working closely with Stanford Hospital as the client, students will not only look at current literature on the topic and build on past practicum research, but also conduct interviews with doctors, nurses, and other health care specialists with the goal of finding out what local hospitals and nursing homes are doing. The aim is to get a more realistic picture of the what one might call the living law of the Directive and the POLST. The ultimate goal is policy recommendations to improve the forms and associated laws and to examine alternative approaches.

Consent of Instructor Form



Clients & Deliverables



  • White paper and suggested revisions to POLST forms

In consultation with Stanford Hospital and Clinics, students conducted a deep stakeholder analysis, including interviews with doctors, nurses, and other health care specialists about their thinking and the circumstances in which they advise patients and families on the use of Advanced Health Care Directives and Physician Orders for Life-Sustaining Treatment (POLST). Students produced policy recommendations to improve the forms, and the laws relating to the forms, as well recommendations on the way that the forms are or can be used.