Advance Directives: Helpful or Overcomplicated Paper Tiger?

Tom Turnbull
Apr 13
3 min read

There’s an ongoing debate among estate planning attorneys that I’ve been closely following about advance directives, which is the document you sign to name a medical decision maker and also express your treatment wishes. The debate is more nuanced than you might expect.

On one hand, these documents are supposed to clearly communicate your medical wishes. On the other, many attorneys (and clients) find them confusing, overly long, and sometimes not even followed.

So what’s really going on?

The Big Question: Do Advance Directives Actually Work?

One Oregon attorney summed it up bluntly:

“The advanced directive is… a piece of paper that’s not self-enforcing… if you are counting on that piece of paper to ensure your wishes are followed, good luck.”

That may sound harsh, but it reflects a real concern:In a fast-moving medical situation, especially in an ER, providers often act based on available information, family input, and liability concerns. I’ve been watching the show The Pit, set in an ER and numerous episodes focus on this and related issues.

Another Oregon attorney put it this way:

“The path of least resistance is to do what the kid says… no one expects the kid to be carrying the [advance directive] in a hip pocket.”

So if that’s true…what’s the point of even having one?

Why Advance Directives Still Matter

Despite the skepticism, most attorneys still believe advance directives are worthwhile but for a different reason than you might think.

1. They Help Families Make Hard Decisions

Even when not strictly enforced, the document can provide emotional clarity:

“The fact that Mom or Dad did sign an AD… is very comforting to children when the time comes… otherwise, it can be very difficult to make that decision.”

This is huge. End-of-life decisions are not just legal, they are deeply emotional. The directive gives families permission to make a difficult decision.

2. They Reduce Conflict

Advance directives are especially valuable when family members disagree on the right decision. They are also critical if someone outside the family is making decisions.

As one attorney noted: hospitals do rely on the document when there’s conflict about who has authority.

3. They Guide (Not Control) Medical Providers

A real-world example: A doctor used the advance directive to push back on a request for aggressive treatment and the family member backed down.

That’s the pattern:The directive doesn’t always dictate care, but it anchors the conversation.

The Real Problem in Oregon: The Messy Form Itself

Here’s where there is near-universal agreement among attorneys in the group:

The current advance directive form is too much. I go further and say it’s flat out terrible. Some attorney comments:

“The advance directive is a miserable document.”

“It is too much for most clients… overwhelming and… unusable by many.”

“Drop the questions about religion… what the person values in life. Keep it simple.”

Most clients simply skip large portions, write “none” over and over, or simply say something like “I trust my family.”

And honestly? That instinct isn’t wrong.

What Actually Makes an Advance Directive Work

The most insightful takeaway from the discussion:

“If you don’t have the conversation [with your loved ones]… [the AD is] like a lottery ticket… probably not worth much.”

This is the key.

An advance directive is not primarily a legal document, it’s a communication tool.

It works best when:

You’ve had real conversations with your decision-makers
Your doctor knows your wishes
The document is accessible (uploaded to medical records if possible)

Without those steps, the document alone has limited impact.

A Subtle but Important Reality

There is also variation in how doctors approach these situations.

One attorney described a personal concern:

“If I get shocked back to life after a 10 second code… I’d want that. If I’m out for six minutes, I wouldn’t.”

That highlights a core issue:

Medical decisions are fact-specific, real-time, and nuanced.No form, no matter how detailed, can perfectly capture that.

So… Should You Have One?

Yes. But with the right expectations.

Think of your advance directive as a guide for your family and doctors and a tool to reduce conflict.

An advanced directive is not a guaranteed enforcement mechanism and it’s certainly NOT a substitute for having the conversation about what type of care you want (and don’t want) with your agents.