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Difficulty: Very hardDecision-Making Capacity

A 75-year-old man is hospitalized with urosepsis. Over the next 24 hours, he develops acute kidney injury and severe oliguria. His blood pressure drops to 85/50 mm Hg, and he is transferred to the intensive care unit for vasopressor support and urgent hemodialysis. The patient is confused, disoriented, and repeatedly asks the nursing staff for his car keys. When the physician attempts to explain the need for dialysis, the patient is unable to demonstrate an understanding of his condition or the proposed treatment.

A valid advance directive (living will), signed by the patient three years ago when cognitively intact, is present in his medical record. It explicitly states: "In the event of a severe but potentially reversible illness, I want all necessary medical interventions, including life support and dialysis, to aid my recovery."

The patient's son, who is legally designated as the healthcare proxy in the advance directive document, arrives at the bedside. Seeing his father agitated and confused, the son says, "I know the document says he wants treatment, but seeing him suffer like this breaks my heart. As his medical power of attorney, I am instructing you to withhold the dialysis and just keep him comfortable."

Which of the following is the most appropriate next step in management?

  1. Proceed with urgent hemodialysis as medically indicatedAnswer
  2. B
    Follow the son's directive and transition the patient to comfort care
  3. C
    Postpone hemodialysis and request an urgent ethics committee consultation
  4. D
    Document the patient's verbal resistance and transition him to inpatient hospice care
  5. E
    Petition the court to revoke the son's status as healthcare proxy before proceeding

Answer

Proceed with urgent hemodialysis as medically indicated.
The correct answer involves proceeding with the life-saving treatment. The patient lacks decision-making capacity due to delirium secondary to urosepsis and uremia. In the absence of capacity, medical decisions are guided by the patient's prior autonomous wishes. A written advance directive (living will) is the strongest legal and ethical evidence of these wishes. The role of a designated healthcare proxy is to utilize 'substituted judgment'—meaning they must make the decision the patient would have made. A proxy does not have the authority to override a patient's clear, applicable, and previously documented directive just because they are emotionally distressed. Because the clinical situation (a severe but potentially reversible illness requiring dialysis) perfectly matches the condition outlined in the living will, the physician is ethically and legally obligated to follow the directive and proceed with the treatment.

Step-by-Step Solution

1
Assess the patient's current decision-making capacity.
The patient lacks capacity due to delirium (confusion, asking for car keys, inability to understand the treatment).
Capacity must be determined before deciding whose authority guides the treatment plan.
2
Determine the hierarchy of substitute decision-making.
The patient has both a written advance directive (living will) and a designated healthcare proxy.
When a patient cannot speak for themselves, prior autonomous expressions must be located.
3
Resolve the conflict between the living will and the healthcare proxy.
The living will directly applies to this exact clinical scenario (reversible illness requiring dialysis) and overrides the proxy's wishes.
A surrogate must use 'substituted judgment' based on the patient's values. A proxy cannot legally or ethically override a patient's clear, documented directive.
4
Execute the appropriate clinical management.
Initiate urgent hemodialysis to stabilize the patient.
The patient previously consented to this life-saving intervention, and the condition is life-threatening without it.

Key Concept

Advance Directive Supremacy over Healthcare Proxy
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Topics

Decision-Making Capacity

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