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Difficulty: EasyAdvance Directives and End-of-Life Care

A 60-year-old woman is evaluated in the surgical intensive care unit following a severe motor vehicle collision. She has sustained a devastating traumatic brain injury and is currently comatose, intubated, and hemodynamically supported. The primary medical team formally determines that she lacks decision-making capacity. Upon reviewing her electronic medical record, the physician finds a legally executed advance directive designating her long-time close friend as her healthcare proxy. Shortly after, the patient's estranged husband, to whom she is still legally married, arrives at the hospital. The designated friend requests the withdrawal of life-sustaining measures, asserting this aligns with the patient's previously expressed values. The husband strongly objects and insists that all aggressive medical interventions continue. Which of the following is the most appropriate action for the physician to take?

  1. Comply with the withdrawal of care requested by the close friendAnswer
  2. B
    Adhere to the continuation of care requested by the husband
  3. C
    Maintain life support until the husband and friend reach a mutual agreement
  4. D
    Petition the local court system to mediate the family disagreement
  5. E
    Wait for the patient to regain decision-making capacity before taking further action

Answer

Comply with the withdrawal of care requested by the close friend
When a patient lacks decision-making capacity, medical professionals must look to a surrogate decision-maker. In the legal hierarchy of surrogacy, a designated healthcare proxy (also known as a durable power of attorney for healthcare) explicitly appointed by the patient in a valid advance directive holds the highest authority. The proxy's decisions legally substitute for the patient's own choices and definitively supersede the preferences, objections, or demands of any default next-of-kin, including a legally married spouse. Therefore, the physician must honor the proxy's request to withdraw care.

Step-by-Step Solution

1
Assess the patient's decision-making capacity.
The patient is comatose and formally determined to lack capacity.
Surrogate decision-makers are only utilized when a patient cannot make decisions for themselves.
2
Determine the highest-ranking surrogate decision-maker according to legal hierarchy.
The patient has a legally executed advance directive naming her friend as her healthcare proxy.
A designated proxy (medical power of attorney) supersedes default next-of-kin, including a legal spouse.
3
Execute the medical decisions made by the legal surrogate.
The physician must follow the friend's directive to withdraw life-sustaining measures.
The proxy holds the legal authority to act on behalf of the patient, overriding the estranged husband's objections.

Key Concept

Hierarchy of surrogate decision-makers
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Topics

Advance Directives and End-of-Life Care

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