WMA Statement on Advance Directives (Living Wills)

Adopted by the 54^th WMA General Assembly, Helsinki, Finland, September 2003
reaffirmed by the 194^th WMA Council Session, Bali, Indonesia, April 2013 and
reaffirmed with minor revisions by the 224^th WMA Council, Kigali, Rwanda, October 2023

PREAMBLE 

An advance directive is a written and signed document or a witnessed verbal statement whereby persons record their wishes regarding the medical care they wish to receive, or not receive, if they become unconscious or otherwise unable to express their will.

This type of document may have different names in different countries (e.g., “living will” or “biological wills”). The acceptability and legal status of such directives may differ from one country to another, depending on social, cultural, religious and other factors.

The majority of persons who draw up such directives are particularly concerned about excessive, ineffective or prolonged therapeutic interventions in the terminal phases of life, in situations where there is clear and irreversible physical or mental degeneration.

The WMA Declaration of Lisbon on the Rights of the Patient states that if the patient is unconscious and “if a legally entitled representative is not available, but a medical intervention is urgently needed, consent of the patient may be presumed unless it is obvious and beyond any doubt on the basis of the patient’s previous firm expression or conviction that he/she would refuse consent to the intervention in that situation.”

RECOMMENDATIONS

1. A patient’s duly executed advance directive should be honoured unless there are reasonable grounds to suppose that it is not valid because it no longer represents the wishes of the patient or that the patient’s understanding was incomplete at the time the directive was prepared. If the advance directive is contrary to the physician’s convictions, provisions should be made to transfer the care of the patient to another consenting physician.
2. If the physician is uncertain about the validity of an advance directive to terminate life-prolonging treatment, he/she should consult family members or legal guardians of the patient concerned and should seek advice from at least one other physician or the relevant ethics committee. The family members or legal guardians should be designated in the advance directive, be trustworthy and willing to testify as to the intention(s) expressed in the advance directive by the signatory. The physician should consider any relevant legislation concerning substitute decision making for incompetent patients.
3. Patients and their family members should be educated on the possibility of having living wills and advised to review their advance directives periodically.
4. In the absence of an advance directive or a legally designated substitute decision maker, physicians should render such treatment as they believe to be in the patient’s best interests.
5. Constituent Members of countries that do not have adequately developed legal frameworks and hospital protocols for advance directives, are encouraged to work with relevant authorities to develop such frameworks, integrate these changes both in the medical curricula and public education, as well as promote awareness among practicing physicians through continuing professional development programs.