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Background: The Patient Self-Determination Act requires that patients entering hospitals be asked if they have an advance directive. This has led to increased awareness of advance directives, yet surgeons have paid little attention to their use among patients undergoing even major surgery. We sought to evaluate the use of advance directives in patients undergoing pancreaticoduodenectomy and esophagectomy., Methods: Patients undergoing these operations between 1996 and 2001 at a university teaching hospital were identified and reviewed for statement of advance directive, its presence in the chart, and impact on patient care., Results: A total of 252 patients met inclusion criteria. The number of patients with an advance directive increased, but had little impact on patient care., Conclusions: More patients having major surgery have advance directives, but the number present in the medical record remains low. Further attention to advance directives would foster increased communication between surgeons and patients and extend patient autonomy.