The Spanish model of advance care planning

Spain is probably one of the most advanced European countries in terms of the legislative and administrative support of Advance Directives (ADs). This process began in the year 2000, when the so called “Oviedo Convention” came into legal effect. Article 9 of this European Convention, establishing that the previously expressed wishes of a patient should be taken into account, opened the door to the development of legal regulations on ADs by the 17 Autonomous Regions in which Spain is divided, and by the Spanish Parliament as well.

As a consequence, all the Regions enacted their own bureaucratic proceedings and created official Registries where citizens can lodge their ADs in order to be known by their doctors when they become incompetent to decide. But in spite of this complex administrative framework the truth is that very few people in Spain have completed an AD: just 57,132 citizens (1.2/1,000 inhabitants) by January 1st 2009.

There are several reasons for this paradoxical situation. One is that Spanish people still think that their families are entitled enough to act as surrogates and that they will do the best for them in collaboration with the health care professionals in the event of incompetency, so ADs are not necessary. A second reason is the lack of cultural habit of speaking about death, and less about their own death! Thirdly, administrations have not developed adequate strategies to inform people about ADs, which remain quite unknown.

In my opinion, however, the strongest reason is that nobody in Spain, neither the politicians nor the clinicians, have understood the AD as a clinical tool that has to be placed mainly in the clinical setting, as a base for high quality end-of-life policies. In summary: there may be a Spanish model for ADs, policies and some isolated experiences of ACP, but a Spanish model of Advance Care Planning does not exist.