Review Question - QID 216721

The care of this patient who has a designated health care proxy with durable power of attorney should adhere to what the proxy believes she would have wanted.

If a patient cannot make decisions, a suitable health care proxy should be identified in order to provide surrogate decision making. The strongest proxy is one with durable power of attorney who is entrusted with providing substituted judgement by considering what the patient would have wanted. Where no official proxy exists, a subjective standard can be applied by considering the advance directives of the patient, such as through a living will. If neither of these forms of surrogate judgement is available, clinicians should identify an individual who makes a decision based on the best interest of the patient. Generally, the priority order is spouse, adult children, parents, siblings, grandparents/grandchildren, and finally a friend.

Cohen-Mansfield et al. examined the use of durable power of attorney among geriatric patients. They found that among those who used this process, 65% chose their closest relative; however, over half of elderly patients had not discussed their healthcare wishes with anyone.

Incorrect Answers:
Answer 1: Do not intubate because her son states that she would not have wanted it is incorrect because the patient has an officially designated healthcare proxy. Even though normally the son would have higher priority than a niece, the official designation is more important than the normal order of substituted judgement.

Answer 2: Do not intubate because the patient seems to be refusing intubation is incorrect because the patient's mental status does not allow for informed decision making. Furthermore, the patient's end-stage dementia likely precludes decision-making capacity even if the patient was not acutely ill.

Answer 3: Do not intubate because this represents futile care is incorrect because the futility of this intervention has not been established for this patient. Physicians are not obligated to perform aggressive futile care such as surgery for inoperable tumors; however, intubation to address respiratory failure does not fall into this category.

Answer 5: Intubate because the living will specifies that she should be intubated is incorrect because a healthcare proxy with a durable power of attorney has decision making priority over a living will. Both agree in this case on whether the intervention is desired, but the substituted judgement of the proxy is the reason the intervention should be performed.

Bullet Summary:
The care of patients who are unable to make decisions should be deferred to a health care proxy with durable power of attorney if one is available.