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Caregivers identified 2 barriers to having advance planning discussions: (1) passive avoidance and (2) active avoidance. These barriers often overlapped with all 3 types of planning discussions (Fig. 1).

Limitations. Advance directives have limitations. 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.

Advance directives are legally recognized documents and doctors must respect your known wishes, but doctors can always refuse to comply with your wishes if they have an objection of conscience or consider your wishes medically inappropriate.

The qualitative analysis identified four barriers to ACP: 1) limited patients' participation in autonomous decision making, 2) cognitive and emotional barriers to discussion, 3) lack of readiness and awareness of early discussion, and 4) unprepared healthcare professionals and healthcare system.

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.

Advance directives do not expire. An advance directive remains in effect until you change it. If you complete a new advance directive, it invalidates the previous one. You should review your advance directives periodically to ensure that they still reflect your wishes.

Checklist: Creating An Advance Health Care Directive200bMedical devices to aid breathing (ventilator)Medical devices to aid nutrition and hydration (tube feeding)Blood transfusions.Dialysis.Antibiotics.Surgery.