What should the care team do for an elderly, communicative patient with respiratory distress, who has an advanced directive declining CPR and advanced airway, but accepting ICU admission and vasoactive medications, when her durable power of attorney relative disagrees with her wishes?

Follow the Patient's Expressed Wishes

The care team should honor the patient's own stated preferences as expressed in her advance directive and current communication, not the durable power of attorney's conflicting wishes, because a competent patient retains full decision-making authority regardless of any previously designated surrogate. 1

Legal and Ethical Framework

Patient Capacity Takes Precedence

• A durable power of attorney only has authority when the patient lacks decision-making capacity 1
• This patient is alert, aware of her surroundings, and communicative—she clearly retains capacity to make her own medical decisions 1
• When a patient has capacity, their directly expressed wishes supersede any surrogate decision-maker's preferences, including those holding durable power of attorney 1

The Role of Advance Directives with Capable Patients

• Advance directives serve to codify patient preferences for times when they cannot speak for themselves 1
• When the patient can actively communicate, their current stated preferences take priority over written advance directives 1
• In this case, both the advance directive AND the patient's current communication align: she wants ICU care and vasopressors but refuses CPR and advanced airway 1

Immediate Actions for the Care Team

Clarify Decision-Making Authority

• Explain to the relative that the durable power of attorney role only activates when the patient loses capacity 1
• Document clearly that the patient currently has decision-making capacity based on her ability to understand her situation and communicate preferences 1
• Inform the relative that attempting to override a competent patient's wishes would violate the patient's autonomy and legal rights 1

Implement the Patient's Wishes

• Transfer to ICU as the patient desires 1
• Provide vasoactive medications for blood pressure support as she has consented to 1
• Ensure clear documentation that CPR and advanced airway (intubation) are not to be performed per the patient's explicit refusal 2
• Continue all other appropriate medical interventions including oxygen, antibiotics, and comfort measures 2

Communication Strategy with the Family

Address the Surrogate's Concerns

• Use empathy to acknowledge the relative's distress and desire to help 3
• Explain that respecting the patient's autonomy is both ethically required and legally mandated 1
• Clarify that the patient's preferences may differ from what the relative would choose, but surrogate decision-making principles require honoring the patient's own values, not the surrogate's 1

Facilitate Family Understanding

• Arrange a family meeting with the patient present (if she agrees) to discuss goals of care 1
• Help the relative understand the distinction between being prepared to serve as surrogate when needed versus having current authority 1
• Explain that the patient's choice to accept some interventions (ICU, vasopressors) while declining others (CPR, intubation) is medically and ethically appropriate 2

Documentation Requirements

Essential Elements to Record

• Document the patient's current capacity assessment including her ability to understand her condition, treatment options, and communicate choices 2
• Record the patient's specific treatment preferences: accepts ICU admission and vasopressors, declines CPR and advanced airway 2
• Note the discussion with the durable power of attorney and clarification of their role 4
• Document that the advance directive aligns with the patient's current expressed wishes 1

Common Pitfalls to Avoid

• Do not defer to the durable power of attorney when the patient has capacity—this is a fundamental violation of patient autonomy 1
• Avoid allowing family pressure to override a competent patient's clearly stated wishes 1
• Do not assume that having an advance directive means the patient cannot make current decisions 1
• Avoid implementing CPR or intubation "to keep the peace" with family—this would constitute battery against a competent patient who has refused these interventions 1, 2

If Capacity Becomes Questionable

• If the patient's capacity fluctuates or becomes unclear, perform a formal capacity assessment 4
• During periods of incapacity, the durable power of attorney would then have authority to make decisions based on the patient's known values and previously expressed preferences 1, 4
• The advance directive would guide decision-making during any period of incapacity 1