Advance directives—an individual's instructions for medical decision-making if the individual is not competent to make decisions—have not met expectations since their introduction about 25 years ago. The authors discuss problems with advance directives and make recommendations for strengthening the directives and promoting their use. The prevalence of advance directives is about 25 percent. Even when provided, physicians may not be aware of their existence and they often do not influence medical decisions. Legal requirements for notarization or restrictions on who may be named as health care proxy, can limit a patient's ability to discuss options with his or her physician. In addition, research has shown that even when a person is aware of another's general values and goals that person may not be able to decipher accurately what the patient would want in a given situation. The authors recommend that advance directives emphasize discussion about and planning for end-of-life care with the patient's physician rather than completion of a legal document. This may require revision of state laws. A patient should be able to designate a health care proxy through an oral statement to the physician as part of a discussion of relevant medical issues. Patients must understand that proxies may need to exercise discretion in making medical decisions for them and courts should defer to proxy decisions. The authors believe that these reforms may result in more informed end-of-life decisions.