Advance directives are legal documents that specify patients' wishes regarding life-sustaining treatment, designate a surrogate decision maker, or both. They were first sanctioned in 1976 to protect patient autonomy. The Patient Self-Determination Act of 1990 required Medicare-certified institutions to provide information about advance directives. Despite debates about their effectiveness, up to 70% of community-dwelling older adults have completed advance directives. This study analyzed data from the Health and Retirement Study to determine the prevalence of decision-making needs and lost decision-making capacity among adults aged 60 or older who died between 2000 and 2006. It also examined the association between advance directives and outcomes of surrogate decision making. Of 3746 decedents, 42.5% required decision making, of whom 70.3% lacked decision-making capacity. Among those who needed decision making, 67.6% had advance directives. Subjects with living wills were more likely to want limited or comfort care than all care possible. Those who requested limited or comfort care were more likely to receive such care. However, those who requested all care possible were far more likely to receive aggressive care than those who did not request it. Subjects with living wills were less likely to receive all care possible than those without. Subjects who had appointed a durable power of attorney for health care were less likely to die in a hospital or receive all care possible than those who had not. These findings suggest that advance directives are associated with care that aligns with patients' preferences. The study found that many elderly Americans needed surrogate decision making near the end of life when they lacked decision-making capacity. Patients who had prepared advance directives received care that was strongly associated with their preferences. These findings support the continued use of advance directives. The study also found that proxies were often the decision makers for patients who needed surrogate decision making. However, there were limitations, including recall and social-desirability biases in proxy reports. The study also lacked data on preferences for subjects without advance directives, which limited comparisons. The findings cannot be generalized to younger adults, who may not have the same need for surrogate decision making. In conclusion, advance directives are important tools for ensuring that care is in line with patients' wishes. The healthcare system should ensure that providers have the time, space, and reimbursement to conduct discussions necessary for end-of-life planning. Data suggest that most elderly patients would welcome these discussions.Advance directives are legal documents that specify patients' wishes regarding life-sustaining treatment, designate a surrogate decision maker, or both. They were first sanctioned in 1976 to protect patient autonomy. The Patient Self-Determination Act of 1990 required Medicare-certified institutions to provide information about advance directives. Despite debates about their effectiveness, up to 70% of community-dwelling older adults have completed advance directives. This study analyzed data from the Health and Retirement Study to determine the prevalence of decision-making needs and lost decision-making capacity among adults aged 60 or older who died between 2000 and 2006. It also examined the association between advance directives and outcomes of surrogate decision making. Of 3746 decedents, 42.5% required decision making, of whom 70.3% lacked decision-making capacity. Among those who needed decision making, 67.6% had advance directives. Subjects with living wills were more likely to want limited or comfort care than all care possible. Those who requested limited or comfort care were more likely to receive such care. However, those who requested all care possible were far more likely to receive aggressive care than those who did not request it. Subjects with living wills were less likely to receive all care possible than those without. Subjects who had appointed a durable power of attorney for health care were less likely to die in a hospital or receive all care possible than those who had not. These findings suggest that advance directives are associated with care that aligns with patients' preferences. The study found that many elderly Americans needed surrogate decision making near the end of life when they lacked decision-making capacity. Patients who had prepared advance directives received care that was strongly associated with their preferences. These findings support the continued use of advance directives. The study also found that proxies were often the decision makers for patients who needed surrogate decision making. However, there were limitations, including recall and social-desirability biases in proxy reports. The study also lacked data on preferences for subjects without advance directives, which limited comparisons. The findings cannot be generalized to younger adults, who may not have the same need for surrogate decision making. In conclusion, advance directives are important tools for ensuring that care is in line with patients' wishes. The healthcare system should ensure that providers have the time, space, and reimbursement to conduct discussions necessary for end-of-life planning. Data suggest that most elderly patients would welcome these discussions.