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The primary outcome is completion of four key ACP behaviours: identification of a surrogate decision maker, communication about goals, completing advance directives and ensuring documents are in the medical record.

Advance directives generally fall into three categories: living will, power of attorney and health care proxy.

Reviewing and changing advance directivesYou can change your directives at any time. If you want to make changes, you must create a new form, distribute new copies and destroy all old copies. Specific requirements for changing directives may vary by state.

Problems with Advance Directives For example, an older adult may not fully understand treatment options or recognize the consequences of certain choices in the future. Sometimes, people change their minds after expressing advance directives and forget to inform others.

If there is evidence to suggest the person has changed his or her mind for example, if they have done something that goes against the advance directivethis would make the advance directive invalid.

What to include in your advance directive: The name and contact information of your healthcare agent or proxy. Answers to specific questions about your preferences for care if you become unable to speak for yourself. The forms and questions asked vary a bit from state to state.

It is known, however, that advance directives (or so called 'living wills') pose serious practical and ethical problems related to continuity, liability, completeness, interpretation and the relationship between rejected and demanded medical treatments, all of which have been intensively discussed (see e.g., 6).