What should be the code status for an elderly woman, hospitalized in the ICU following a myocardial infarction, who was initially intubated and resuscitated, but now expresses a desire to not be reintubated if her condition worsens, despite her advance directive stating full code and her surrogate decision maker disagreeing with her current wishes?

Code Status Should Be Changed to DNR/DNI Based on Patient's Current Expressed Wishes

The patient's current, clearly expressed wishes to not be reintubated should be documented as her code status (DNR/DNI), superseding both the advance directive and the surrogate's objection, because she currently has decision-making capacity and understands the consequences of her choice. 1

Primacy of Current Patient Preferences Over Advance Directives

When a patient with decision-making capacity expresses preferences that differ from their advance directive, the current expressed wishes take precedence over previously documented preferences. 1 The American College of Critical Care Medicine and American Thoracic Society explicitly state that clinicians should elicit values, goals, and preferences directly from patients themselves whenever they are able to communicate, even when they appear weak or were recently critically ill. 1

• Advance directives represent what patients believed they would want at the time of writing, not necessarily what they want now when facing the actual clinical situation. 1
• The goal of surrogate decision-making is to enact the patient's previously stated preferences only when those preferences are "applicable and contemporary." 1
• When the patient can currently express their wishes with capacity, those current wishes override prior written directives. 1

Assessment of Decision-Making Capacity

The critical determination here is whether this patient has decision-making capacity despite being "very weak." 1

Key capacity assessment criteria:

• Does she understand her medical condition and prognosis? (Yes - she was informed about her MI and recent intubation) 1
• Does she understand the consequences of refusing reintubation? (Yes - the scenario explicitly states "she understands that the consequence of not being reintubated is that she will die") 1
• Can she communicate a consistent choice? (Yes - she is "repeatedly saying" the same preference) 1
• Is her decision based on her own values rather than depression or delirium? (Requires clinical assessment, but repeated consistent statements suggest capacity) 1

Physical weakness alone does not indicate lack of decision-making capacity. 1 The fact that she can clearly articulate her wishes, understands the consequences, and is making statements consistent with common values (not wanting prolonged suffering) suggests she likely has capacity. 1

Role of the Surrogate When Patient Has Capacity

When a patient has decision-making capacity, the surrogate's role is suspended. 1 The surrogate's authority only applies when the patient lacks capacity to make their own decisions. 1

• The relative's belief that she is being "emotional" does not override the patient's autonomous decision-making if she has capacity. 1
• Surrogates sometimes make errors due to projection bias, making decisions based on their own values rather than the patient's values. 1
• The surrogate's disagreement, while understandable emotionally, is not legally or ethically determinative when the patient can speak for herself. 1

Proper Documentation Requirements

The DNR/DNI order should include: 2, 3

• Clear statement that the patient had decision-making capacity at the time of this decision 2, 3
• Date of DNR/DNI order implementation 2, 3
• Specific interventions to be withheld: no chest compressions, no defibrillation, no endotracheal intubation, no mechanical ventilation 2
• Explicit statement that DNR/DNI does not affect other treatments (oxygen, IV fluids, medications, antibiotics, comfort measures) unless specifically noted 2, 4
• Documentation of the discussion with the patient, including her expressed values and understanding of consequences 2, 3
• Patient's signature (she is capable) 2
• Note documenting the surrogate's disagreement and the clinical team's assessment that the patient has capacity 3

Communication Strategy with the Surrogate

While the patient's wishes should be honored, the clinical team should attempt to help the surrogate understand the ethical and legal framework: 1

• Explain that the patient currently has decision-making capacity and therefore makes her own decisions 1
• Clarify that the surrogate's role is to make decisions for the patient when she cannot, not to override her current wishes 1
• Acknowledge the surrogate's emotional distress and offer support 1
• Consider involving palliative care or ethics consultation to facilitate this difficult conversation 1
• Explain that respecting patient autonomy, even when family disagrees, is both legally required and ethically appropriate 1

Critical Pitfalls to Avoid

Do not delay implementing the patient's wishes while trying to convince the surrogate. 1 This would violate the patient's autonomy and potentially subject her to unwanted interventions if she deteriorates. 1

Do not assume weakness equals incapacity. 1 Post-extubation weakness is expected after critical illness and does not indicate inability to make decisions. 1

Do not write vague or partial code orders. 2, 5 Clearly specify DNR/DNI with explicit interventions to be withheld, as partial or unclear orders lead to confusion and potentially harmful outcomes. 5

Ensure the order is reviewed if her condition or preferences change. 2, 3 DNR/DNI orders should be reviewed periodically, particularly with significant changes in clinical status. 2