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Table of Contents
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
4c* Advance Directives
[C4:1] A patient with metastatic pancreatic cancer is admitted to the hospital with shortness of breath. The patient does not have decisional capacity. The patient’s youngest offspring, who holds the medical power of attorney, makes the patient DNR. The patient’s eldest offspring disagrees with this decision. What should be done?[C4:2]
- A. Get a court order before complying.
- B. Until consensus is reached, delay the DNR.
- C. Comply with the older offspring’s decision not to make the patient DNR.
- D. Comply with the younger offspring and make the patient DNR.
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TAC: Think - Assess - Conclude
I. Think: What is the question?
[C4:3] Who legally has decision-making authority?
II. Assess: Specify & Balance the four principles of medical ethics
Patient: 1) Autonomy - Informed Consent
[C4:4] The patient does not have decisional capacity, and previous oral or written consent of their wishes is not available. No living has been written and signed by the patient indicating their medical treatment desires. Since no higher authority exists, then the durable power of attorney, more specifically known as medical power of attorney (POA), is the next level of authority in which the patient appoints a person explicitly to be the patient’s legal surrogate decision maker or proxy if the patient becomes incapacitated, hence the term durable. In this case, the patient has appointed the younger offspring to be the patient’s legal surrogate.
[C4:5] However, what needs to be asked by the practitioner here, is why does the patient’s older offspring disagree with the younger offspring’s DNR assignment? Is it because the older offspring believes that the patient would not have chosen that? If so, what is the evidence? The younger offspring also must realize that they are supposed to make decisions by using substituted judgment. This means that the younger offspring must substitute their own goals, values, and priorities with that of the patient when making decisions for the patient. Another question that the practitioner needs to be asking is why does the younger offspring believe that their mother would or would not want to be classified as DNR? If there is no solid evidence either way, even after listening to the sibling’s objections, then the surrogate is obliged to decide based on the patient’s best interests. All parties involved must realize that being classified as DNR does not affect any treatment options or treatment care; instead, it only means that CPR will not be performed if the patient stops breathing or their heart stops.
[C4:6] Therefore, if the surrogate uses substituted judgment in making the patient DNR, then the doctor has the legal and moral obligation to make the patient DNR regardless of the objections from the patient’s older offspring as the younger offspring has full legal authority.
[C4:7] When there are family disagreements, especially when all the family members have equal weight in a decision, it is essential to promote discussion and consensus. In this case, although it is essential for the practitioner to promote discussion and consensus, in the end, it is still ultimately the younger offspring who has the legal authority, as that is who the patient autonomously chose to be their medical decision-maker if and when they were to become incapacitated without decisional capacity.
Practitioner: 2) Beneficence & 3) Nonmaleficence
[C4:8] Professional beneficence (do good) and professional nonmaleficence (do no harm) demands that futile medical treatment should not be conducted. Depending on the severity of the metastatic pancreatic cancer, it is probable that CPR would not provide any benefits and would only do more harm. Having a DNR in the chart can benefit the patient and minimize both harm and the risk of harm. Lastly, the practitioner has a legal and moral responsibility to respect and honor the authorized surrogate, as determined legally by the durable power of attorney as long as the surrogate is using substituted judgment, that is, making decisions using the patient’s reasonable goals, values, and priorities and not their own, and if that is not possible by using the patient’s best interests.
Public Policy: 4) Justice
[C4:9] All persons have the social right of self-determination manifested through a durable power of attorney (POA). The practitioner is legally bound to recognize the surrogate’s decisional-authority when made using substituted judgment. If a substituted judgment is not possible, then the surrogate is obliged to make medical decisions by maximizing the patient’s best interests, and the practitioner should respect those decisions. Failure to respect the DNR is legally tantamount to a physical battery or unauthorized bodily contact.
[C4:10]
III. Conclude: Nationally or Professionally True Answer
[C4:11] The recommendation would be for the practitioner to promote discussion and consensus between all parties involved. However, ultimately the practitioner is legally and morally bound to comply with the DNR order if the surrogate used substituted judgment, or if the patient’s wishes are not determinable, then by the surrogate using the patient’s best interests in the making of the DNR decision.
[C4:12] The younger offspring’s legal decision-making authority through the durable power of attorney persists as long as the medical decisions are being made using substituted judgment, and if a substituted judgment is not possible, then in the patient’s best interests.
Answer Options: [C4:11]
(Choice A) Get a court order before complying.
A is wrong because the durable power of attorney gives the legal authority to make medical decisions if done using substituted judgment and if a substituted judgment is not possible, then the surrogate uses the patient’s best interests. If disagreements arise as to whether or not those conditions have been met, then adjudication by a court may be necessary, or the practitioner can conscientiously object.
(Choice B) Until consensus is reached, delay the DNR.
B is wrong, as consensus is not a necessary condition for usurping the authority of the legal surrogate. When there is disagreement, the practitioner should encouraged discussion and consensus.
(Choice C) Comply with the older offspring’s decision not to make the patient DNR.
C is wrong, as the younger offspring has been given the legal authority by the patient to make medical decisions if the patient were to be incapacitated and without decisional capacity, not the older offspring. As the decision-maker, the younger offspring must make the medical decisions using substituted judgment, and if that is not possible, then using the patient’s best interests.
(Choice D) Comply with the younger offspring and make the patient DNR.
D is the correct answer. The patient appointed the younger offspring to have legal decision-making authority through the durable power of attorney. This decisional authority persists as long as the medical decisions are being made using substituted judgment, and if substituted judgment is not possible, then in the patient’s best interests.
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Assessment
Surrogate Authority
Principles
DNR
No DNR
Autonomy
X
Beneficence
X
Nonmaleficence
X
Justice
X
