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Living wills cannot cover all conceivable end-of-life decisions. There is too much variability in clinical decision making to make an all-encompassing living will possible. Persons who have written or are considering writing advance directives should be made aware of the fact that these documents are insufficient to ensure that all decisions regarding care at the end-of-life will be made in accordance with their written wishes. They should be strongly encouraged to communicate preferences and values to both their medical providers and family/surrogate decision makers.
It also is important to realize that advance directives do not always fit all situations that may require "life sustaining" procedures. For example, a short term intervention that might necessitate the use of temporary "life sustaining" procedures may be necessary to incrase the quality of a patient's life, such as temporary intubation for surgery conducted for palliative purposes. An example might be surgery to remove a tumor mass to improve a patient's breathing or swallowing.
Another potential limitation of advance directives is possible changes in the patient's preferences over time or circumstance. A living will may become inconsistent with the patient's revised views about quality of life or other outcomes. This is yet another reason to recommend that patients communicate with their physicians and family members about their end-of-life wishes.