If advance directives are implemented properly, this could, in the long term, be a vehicle for more appropriate utilization of health care services and health care technology. Yet in our own large agency we find few patients and families making the choice to have advance directives. This confirms that real change in this area is not being achieved through legislative or regulatory mandate but rather through an interactive process. Home care agencies are in a strong position to effect this change. Next we need to move beyond compliance and into an understanding of how advance directive requirements must be integrated with a patient, the family, and their culture, along with the ongoing relationships that evolve between the nurse and the patient over time.