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Difficulty: MediumInformed Consent and Refusal of Care

A 62-year-old woman is admitted to the hospital after suffering a massive left middle cerebral artery ischemic stroke. She is stabilized medically but has severe global aphasia and profound right hemiplegia. Repeated assessments show she is entirely unable to comprehend medical information, communicate her wishes, or demonstrate decision-making capacity. A formal swallowing evaluation reveals severe oropharyngeal dysphagia with a high risk of aspiration, and the medical team determines that placement of a percutaneous endoscopic gastrostomy (PEG) tube is indicated for long-term nutritional support. The patient has a legally executed advance directive from two years ago that specifically appoints her longtime neighbor and close friend as her durable power of attorney for healthcare. The document does not explicitly mention preferences regarding artificial nutrition. When approached by the medical team, the friend requests that the PEG tube be placed. Shortly after, the patient's biological adult daughter, who lives out of state and visits annually, arrives at the hospital and adamantly demands that the PEG tube not be placed. The daughter insists that as the patient's closest living blood relative, she is the rightful decision-maker. Which of the following is the most appropriate next step in management?

  1. Obtain consent for the procedure from the patient's friend.Answer
  2. B
    Follow the daughter's directive to withhold the procedure.
  3. C
    Defer the decision until a hospital ethics committee provides a recommendation.
  4. D
    Petition the court to appoint a legal guardian to resolve the dispute.
  5. E
    Proceed with the feeding tube placement under the principle of implied consent.

Answer

The most appropriate next step is to obtain consent for the procedure from the patient's friend, as the legally appointed healthcare proxy.
The correct course of action is to obtain consent from the legally appointed healthcare proxy (the friend). When a patient loses decision-making capacity, medical professionals must look to an advance directive if one exists. A durable power of attorney for healthcare (DPOA-HC) allows a patient to designate a specific person to make medical decisions on their behalf. This legally designated proxy possesses the highest authority in the surrogate hierarchy, explicitly overriding the default next-of-kin hierarchy (such as spouses, adult children, or parents). Therefore, despite the daughter's biological relationship and objections, the friend holds the legal right to consent to the PEG tube placement based on substituted judgment or the patient's best interests.

Step-by-Step Solution

1
Assess the patient's medical decision-making capacity.
The patient lacks capacity.
Severe global aphasia from the stroke prevents the patient from comprehending information and communicating preferences.
2
Determine the legal surrogate decision-maker.
The friend is the rightful surrogate decision-maker.
The patient executed an advance directive designating the friend as the durable power of attorney for healthcare. This legal designation supersedes the default state-mandated next-of-kin hierarchy.
3
Determine the appropriate action regarding the conflict with the daughter.
Proceed with the friend's decision.
Because the friend has sole legal authority to make healthcare decisions on the patient's behalf, the daughter's objections do not override the proxy's consent.

Key Concept

In the absence of patient decision-making capacity, a legally appointed healthcare proxy (durable power of attorney for healthcare) takes absolute precedence over biological next-of-kin.
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Topics

Informed Consent and Refusal of Care

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