A 74-year-old woman with metastatic pancreatic cancer is admitted to the intensive care unit with septic shock secondary to severe pneumonia. She is intubated, requires dual vasopressor support, and is obtunded, lacking clinical decision-making capacity. The medical team determines that further aggressive interventions are highly unlikely to alter her terminal trajectory.
Three years ago, the patient completed a legally valid advance directive in which she explicitly appointed her long-time friend as her durable power of attorney for healthcare (DPOA-HC). The directive also broadly stated her desire to avoid "prolonged suffering on machines" if her prognosis became terminal.
The patient's husband of 40 years arrives at the hospital. He is deeply distraught and insists that the medical team initiate continuous renal replacement therapy for newly developed acute kidney injury. The friend arrives shortly after and requests that life-sustaining treatments be withdrawn and the patient be transitioned to comfort-focused care, consistent with the advance directive.
Which of the following is the most appropriate action regarding this patient's care?
- ADefer to the husband's requests, because a legally married spouse maintains default statutory priority over non-relative appointees for end-of-life decisions.
- BSeek a court order to formally declare the patient legally incompetent before allowing the surrogate to withdraw life support.
- Honor the decisions of the friend, as a formally designated healthcare proxy legally supersedes a spouse in the surrogate hierarchy.Answer
- DMaintain all current life-sustaining therapies indefinitely until the husband and the friend can reach a unanimous agreement.
- ERecommend transfer to a long-term acute care facility to continue life support while the family and proxy resolve their dispute.