When Written Advance Directives are not Enough Kristi L. Kirschner, MD Northwestern University Feinberg School of Medicine, 345 East Superior, Suite 1122, Chicago, IL 60611, USA What do you value most in life? Under what circumstances would you think death preferable to continued life? How certain are you? Are you certain enough to put your wishes in writing? And what if ‘‘you’’ somehow are fundamentally changed, say by a brain injury or life-altering event? Should we hold you to those prior expressed wishes? Thinking about an advance care plan, let alone formally executing one, is daunting for most people. We don’t like to think about bad things happening to us or what our death might be like. We may feel inadequate and uncertain about what we want in various circumstances, particularly when our lives may be at stake. As dynamic, evolving beings, we also frequently change our minds about issues as inconsequential as our favorite colors or foods and issues as significant as where we live, whom we marry, and how we choose to spend our time. These changes may occur as the result of new experiences or information. Perhaps we become involved with a new religion, personal psychotherapy, or have a ‘‘wake-up call’’ as the result of an illness or injury. Less dramatic events or seemingly minor decisions, such as whom we associate with or how we spend our free time, can also have a profound effect on our thoughts, values, and perspectives. By necessity, all living organisms interact with and are modified by their environment. Changes of thoughts and values can occur in the context of intact cognitive, perceptual, and emotional processing systems—what we would call, in other words, a ‘‘healthy’’ brain. What about circumstances in which our minds are literally changed for us, by brain injury or a disease process for example? We may no longer be able to think and process information in the same way. We may not even be able to remember who we were before, but we still have feelings, 0749-0690/05/$ – see front matter D 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.cger.2004.08.006 geriatric.theclinics.com E-mail address: kkirschner@rehabchicago.org Clin Geriatr Med 21 (2005) 193 – 209