Background Many people do not wish to prolong their lives at all cost. Advanced care directives (ACDs) are used to operationalise these wishes. However, it has proven difficult to encourage individuals, even those with serious illnesses, to complete ACDs. Public health and behavioural economic strategies have been used in a variety of contexts to increase desirable outcomes.

Aim To determine the wishes and attitudes of various populations at the end of life and to develop alternative strategies to ensure that these wishes are respected.

Methods A literature review was conducted to answer the following: what percentage of people can be classified as life extenders (those who believe that extending life is paramount, regardless of quality of life), what is the uptake of ACDs in various contexts and what behavioural economic strategies have been used to increase the uptake of ACDs?

Results Life extenders are rare in some populations. The uptake of ACDs is highly context dependent with prevalences of 0–80%. Behavioural economic approaches for increasing the efficacy of ACDs have been suggested but not studied.

Discussion In populations where life extenders are rare it appears ethically defensible to make comfort care the default in end of life (EOL) situations. These situations require careful definition. Decision-making about EOL care may improve by providing information about community attitudes.

Conclusion New approaches are required to make EOL care accord to people’s wishes. Public health and behavioural approaches seem likely to achieve this.