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Difficulty: MediumAdvance Directives and Surrogate Decision Making

A 62-year-old woman is evaluated in the hospital two weeks after suffering a massive ischemic stroke. She is currently aphasic, bedbound, and lacks decision-making capacity. She has failed multiple swallow evaluations, and the medical team recommends the placement of a percutaneous endoscopic gastrostomy (PEG) tube for long-term enteral nutrition. The patient is a widow and has never completed an advance directive or designated a healthcare proxy. Furthermore, she had never discussed her preferences regarding artificial nutrition with her family.

Three family members are present to discuss her care plan:
- Her 35-year-old son requests that the PEG tube be placed to sustain her life.
- Her 85-year-old mother, who resides with the patient, refuses the procedure, feeling it would only prolong suffering.
- Her 60-year-old brother, who holds a Durable Power of Attorney for Finances, also refuses the procedure, asserting his legal authority.

Which of the following is the most appropriate next step regarding the patient's medical care?

  1. A
    Withhold the PEG tube placement as directed by the mother
  2. B
    Delay the procedure until all three family members reach a unanimous consensus
  3. Proceed with the PEG tube placement as directed by the sonAnswer
  4. D
    Withhold the PEG tube placement as directed by the brother
  5. E
    Request a court-appointed medical guardian to make the decision due to family conflict

Answer

Proceed with the PEG tube placement as directed by the son
When a patient lacks decision-making capacity and has not designated a healthcare proxy or created an advance directive, medical decisions fall to a statutory surrogate. State laws establish a priority hierarchy to determine who has legal authority. The standard hierarchy is: spouse, followed by adult children, followed by parents, and then adult siblings. Because the patient in this scenario is a widow, her adult son becomes the highest-ranking statutory surrogate. His medical decisions are legally binding, and the physician should follow his directive to place the PEG tube.

Step-by-Step Solution

1
Determine the patient's decision-making capacity and the presence of any advance directives.
The patient lacks capacity and has no advance directives or designated healthcare proxy.
This establishes the legal necessity to identify a statutory surrogate decision-maker.
2
Identify the available family members and assess their legal standing.
Available family members are a son, a mother, and a brother (with Financial POA).
State laws dictate a specific priority hierarchy to prevent decision-making deadlocks when family members disagree.
3
Apply the statutory surrogate hierarchy to the present family members.
The adult son has the highest legal priority (above parents and siblings).
The standard hierarchy prioritizes family members in this order: spouse > adult children > parents > adult siblings.
4
Evaluate the brother's claim of authority.
The Financial Power of Attorney is dismissed for this medical context.
A Financial POA grants no legal authority over healthcare decisions.

Key Concept

In the absence of an advance directive or designated healthcare proxy, medical decisions are made by a statutory surrogate based on a legal hierarchy, which is typically: spouse > adult children > parents > adult siblings.
Estimated Time:1m 0s
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Topics

Advance Directives and Surrogate Decision Making

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