Dichotomy in Health Care Policy-Reply

Peter A. Singer, MD, MPH, FRCPC, FACP; Frederick H. Lowy, MD, FRCPC
Arch Intern Med. 1993;153(2):260. doi:10.1001/archinte.1993.00410020103011.
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Wald makes several interesting points in his letter, and we are pleased to have the opportunity to respond to them.

First, he suggests that patients are unwilling to complete advance directives and, even if they do, such directives are not helpful when the patient becomes incapable. Our clinical experience is just the opposite. We find that patients do want to discuss the possible use of lifesustaining treatments in their future care; this positive attitude has been shown in many studies.1-5 Moreover, although we agree with Wald that early advance directives refusing heroic measures in case of terminal illness were too vague to be useful, more recent directives6,7 are more specific and, thus, more helpful for physicians.8

Second, Wald points out that it is difficult to know ahead of time which patients receive inappropriate care. However, his definition of inappropriate care rests on whether the patient survives. In


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