Background Respecting patient autonomy when decision-making capacity is lost is an important ethical goal in the delivery of healthcare. But without a comprehensive approach to ACP, caregivers may experience a considerable ethical burden when executing advance directives (AD) due to lack of consistence, institutional barriers or value differences between stakeholders.

Aim To propose a taxonomy of ethical issues concerning the implementation of AD in order to facilitate the discussion within the structures of clinical ethics and ACP training for professionals.

Methods The literature describes the ethical challenges in executing AD in settings of poor ACP. But it only pays scant attention to the different underlying etiologies. Not addressing them may negatively affect the mental health of caregivers, job retention and the quality of care delivered.

Results Ethical challenges in executing AD’s can be best prevented by a comprehensive ACP. But they nevertheless occur. They can be attributed either to the complexity of the situation (e.g. outdated documents, unforeseen course of the disease, unclear professional obligations) or to the wrongness of actions (e.g. legal representatives or healthcare workers acting against the patient’s will).

Discussion Distinguishing the underlying aetiology of ethical issues indicates a course of action: In cases of complexity, a principled resolution is needed which acknowledges the conditions of ethical uncertainty, in cases of wrongness a concerted action in order to prevent further damage.

Conclusion By introducing this taxonomy, clinical ethics and ACP training education has an important task in orientating healthcare workers who face ethical challenges when implementing AD’s.