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Difficulty: MediumEnd-of-Life Care Ethics

An 81-year-old man is admitted to the medical ward for management of severe bone pain caused by metastatic prostate cancer. His medical history includes mild vascular neurocognitive disorder resulting from a lacunar infarct two years ago. After a discussion regarding the futility of further antineoplastic therapy, the patient states, 'I understand that my cancer is spreading and cannot be cured. I do not want any more blood draws or hospital treatments. I just want to go home and receive medications to keep me comfortable.' He accurately describes his diagnosis, prognosis, and the implications of his decision. His grandson, who was legally appointed as the durable power of attorney for healthcare five years ago, is present and strongly disagrees. The grandson insists, 'My grandfather has a neurocognitive disorder and cannot understand complex medical issues anymore. As his proxy, I am instructing you to continue all active treatments.' Which of the following is the most appropriate next step in management?

  1. Implement a home hospice care plan according to the patient's expressed goalsAnswer
  2. B
    Adhere to the grandson's directives because the durable power of attorney is actively in effect
  3. C
    Wait for a judicial ruling regarding the patient's legal competence before changing the care plan
  4. D
    Transfer the patient to a skilled nursing facility for continued active oncologic management
  5. E
    Contact state adult protective services to report the grandson for suspected elder abuse

Answer

Implement a home hospice care plan according to the patient's expressed goals
The correct action is to honor the patient's request for comfort-focused care and home hospice. The patient demonstrates all criteria for clinical decision-making capacity: he communicates a clear choice, understands his diagnosis and prognosis, appreciates the consequences of stopping treatment, and provides a rational justification. A diagnosis of mild neurocognitive disorder does not automatically result in a loss of capacity, as capacity is decision-specific. When a patient possesses clinical capacity, their autonomous decisions supersede any instructions from a designated healthcare proxy.

Step-by-Step Solution

1
Assess the patient's clinical decision-making capacity.
The patient demonstrates the ability to communicate a choice, understand the information, appreciate the consequences, and reason about the options.
Capacity must be established before accepting a patient's refusal of life-sustaining treatment, especially in a patient with a history of cognitive impairment.
2
Evaluate the legal standing of the grandson's demand.
The grandson currently has no authority to direct care.
A designated healthcare proxy or durable power of attorney only becomes active when the patient lacks clinical capacity.
3
Determine the appropriate disposition.
The patient's request for comfort-focused care at home should be honored.
An autonomous, capable patient has the right to refuse any medical intervention and dictate their end-of-life care goals.

Key Concept

Clinical decision-making capacity and surrogate activation
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Topics

End-of-Life Care Ethics

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