Ask a different question, get a different answer: why living wills are poor guides to care preferences at the end of life.

CONTEXT Living wills have a poor record of directing care at the end of life, as a copious literature attests. Some speculation centers on the questionable correspondence between the scenario described in living wills versus the real-life circumstances that typically arise at the end of life. OBJECTIVE To assess the strength of association between responses to a standard living will question and preferences for treatments in six end-of-life scenarios. DESIGN Cross-sectional. SETTING Telephone interviews. PARTICIPANTS Two hundred two community-dwelling men and women 70 years of age or older in the greater Philadelphia area. MAIN OUTCOME MEASURES Strength of preferences for four life-sustaining treatments in each of six poor-health scenarios. RESULTS Associations between responses to the standard living will question and preferences for treatment (means across the four) in six specific scenarios were statistically significant but modest in size, accounting for 23% of variance at most. The association for the worse-case scenario (severe stroke with coma) was significantly stronger than for any other association. CONCLUSIONS The modest correspondence between living will responses and wishes for life-sustaining treatment in specific scenarios helps to elucidate the living will's poor performance. Presentation of more realistic end-of-life scenarios should improve the living will's ability to guide care, as well as preparing patients and families better for the end of life.