Columbia University College of Physicians & Surgeons New York, New York
Abstract: Advance directives exist so that a person’s known wishes for their healthcare can be carried out long after they lose capacity to make those decisions. In general, advance directives serve as a roadmap for a patient’s care and when duly executed, should be upheld. Advance directives are meant to make a surrogate or healthcare proxy’s decisions regarding the patient’s care easier. However, there are times when they can actually make the situation more challenging.
Are there specific circumstances under which it would be ethical to overturn a patient’s advance directives? What are the factors weighing into such a decision? We review a framework listing five factors to consider in cases where overriding a patient’s advance directives is a serious consideration. Starting with a clinical ethics case, we walk through the competing principles to weigh them to make a determination in the case at two inflection points in the patient’s care. We then talk about three classic cases where the patient’s advance directives could be reversed in either direction (blanket DNR/DNI to temporarily become full code for a high-yield, low-risk intervention; full code to become DNR/DNI due to a terminal and unforeseen new diagnosis; and a switch to full code in the case of iatrogenic harm).
Keywords: advance directives, best interest standard, wrongful life
Learning Objectives:
After participating in this conference, attendees should be able to:
Review four clinical ethics cases where the key question is whether or not to override a patient's advance directives
To review a framework using 5 factors to weigh in weighing a surrogate's wishes, a patient's previously expressed wishes and the best interests of the patient
To review legal implications of overriding a patient's advance directives e.g. the "wrongful life" case
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