The debate over the 2010 health care reform legislation sharpened public discussion on end-of-life decision making for many Americans. Attorneys—practitioners and academics alike—emphasize the values of autonomy and independence in end-of-life decision making and the role of attorneys and courts. But the private implementation of legal documents designed to foster these values can be highly problematic for health care practitioners, family members, and even patients themselves. Why is this? Why is there such a powerful disconnect between rhetoric and implementation on end-of-life decision making? What role does the law play in fostering this disconnect? What role might health care payment systems play?

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