Hospitals throughout the United States were surveyed in 1988 to determine their policies on advance directives, including living wills and durable power of attorney documents. Sixty-seven percent of the 219 respondents reported some formal policy regarding advance directives. Most institutions made it the patient's responsibility to notify physicians of the existence of a directive, with only 4% of the hospitals querying the patient directly about an advance directive. State legislation on advance directives correlated positively with the drafting of a formal policy by hospitals, whereas the existence of an institutional ethics committee appeared to have no effect on whether a hospital had a formal policy on directives. The authors comment on the legal and ethical aspects of hospital policies on advance directives, and argue that all acute-care hospitals should establish a formal policy regarding directives and should ask patients upon admission if a directive has been completed.