When Not to Follow an Advance Directive

by: Eric Widera (@ewidera)

An 85-year-old woman with moderate Alzheimer’s disease who enjoys walking in her nursing home’s garden with her walker has fallen and broken her hip. An advance directive signed by the patient states a preference for “Comfort Measures Only,” and specifically states that she does not want to be transferred to the hospital. The physician believes that surgery would provide long-term pain relief and the chance to maintain some mobility.

What do you do? How do you reconcile her previously expressed hypothetical wishes in an Advance Directive with what is now a rather unanticipated scenario?

In a paper published today in JAMA Internal Medicine, Alex Smith, Bernard Lo, and Rebecca Sudoredeveloped a 5-question framework to help physicians and surrogates through the decision making process in time like this. The framework proposes 5 key-questions to untangle these conflicts:

1. Is the clinical situation an emergency? 
2. In view of the patient’s values and goals, how likely will the benefits of the intervention outweigh the burdens? 
3. How well does the advance directive fit the situation at hand? 
4. How much leeway does the patient provide the surrogate for overriding the advance directive? 
5. How well does the surrogate represent the patient’s best interests?

So, how do the authors balance her previously expressed wishes with that which her surrogate may think is in her best interests?

Based on the framework, the paper argues that it is ethically appropriate for the physician and daughter to override the patient’s previously stated wishes in her Advance Directive and transfer her to the hospital for surgery.   The situation isn’t an emergency, the benefits of pain relief and quality of life with surgery likely outweigh the harms, the advance directives are not a perfect fit and they also grant the surrogate leeway, and the surrogate represents the patients best interest well.

Do you agree?

NOTE: This is one in a series of posts for “Code Discussion Week.”   Here is a list of the rest:

• It’s all in the Framing: How to Influence Surrogates’ Code Status Decisions
• Changing the Default Code Stus to DNR for Seriusly Ill Patients
• The Clinician as the Choice Architect – Nudging an Informed Choice About CPR
• What Is A “Natural” Death, Anyway?
• Discussing CPR: What Makes It So Different?
• CPR Discussions and Harm Reduction
• When Not to Follow an Advance Directive