In summary, ADs have become an important tool in the armamentarium of the primary care physician. The concepts of advance planning for end-of-life care and avoidance of overly burdensome, ultimately futile care have been widely accepted by patients and physicians. Given an appropriate sensitivity for cultural variations, thoughtful discussions of end-of-life preferences lead patients to feel more cared for and more in control of their health care. Ethical and legal barriers to limiting care at the end of life have been debated widely and largely resolved in favor of patient autonomy. Indeed, the PSDA encourages health care facilities and insurers to promote the widespread use of ADs. Nevertheless, ADs continue to be used by a minority of Americans. Barriers include patient and physician discomfort with initiating sensitive discussions as well as financial and time constraints. Physician education can overcome the discomfort often experienced when discussing end-of-life care, as well as help convince busy physicians of the importance of raising these issues. As third-party payers recognize the potential value of ADs, reimbursement may begin to improve. Many model AD documents have been proposed and have varying legal standing from state to state. Experience with various forms enables physicians to tailor these important discussions to the needs of each patient and family. The potential rewards of the widespread use of ADs, in potential cost savings and more importantly as less stressful, less ambiguous, and more compassionate end-of-life experiences for patients, families and physicians are enormous.