advance directive

**Definition:** Instructions made by a patient with decision-making capacity that guide care if they later become incapacitated.

**Main types:** 1. **Living will (instructional directive):** Specifies which treatments the patient would accept or refuse in particular situations (e.g., CPR, mechanical ventilation, artificial nutrition/hydration, dialysis, antibiotics) usually in terminal illness or persistent vegetative state. 2. **Durable power of attorney for health care (health care proxy/agent):** Designates a person to make medical decisions on the patient's behalf when the patient lacks capacity. "Durable" means it remains in effect after incapacity. Generally preferred over a living will because the proxy can interpret wishes in unanticipated situations. 3. **Related portable medical orders:** DNR/DNI orders and POLST/MOLST (Physician/Medical Orders for Life-Sustaining Treatment). POLST is a medical order intended for seriously ill or frail patients near end of life, not a substitute for an advance directive and not typically for healthy people.

**Key principles/hierarchy (high-yield for ethics questions):** - Patient autonomy is the guiding principle. A patient with capacity can revoke or change an advance directive at any time, and their current competent wishes override a prior directive. - If no directive exists and the patient lacks capacity, use a **surrogate hierarchy** (approximately): previously appointed proxy, then spouse/domestic partner, then adult children, then parents, then siblings, then other relatives/friends. Surrogates should use **substituted judgment** (what the patient would have wanted), then **best interest** standard if wishes are unknown. - An oral statement can serve as an advance directive, but written documents carry more weight. Clear and convincing evidence of wishes is the standard in some states (e.g., Cruzan v. Missouri, 1990). - Directives apply only when the patient lacks capacity. Capacity is determined by the treating physician (decision-specific, not global). - Advance directives are generally valid across settings, but state laws vary. Pregnancy may affect enforcement in some states. - A directive refusing a specific treatment (e.g., a "no blood transfusion" card in a Jehovah's Witness patient) should be honored if valid and applicable. - Emergency exception: if no directive is available and the patient is unstable, treat under implied consent. - Physicians cannot be compelled to provide medically futile or non-beneficial care; conflicts are handled through ethics consultation and transfer of care if necessary. - Family members cannot override a valid directive or a designated proxy's decisions made in line with the patient's wishes. If the proxy's decisions clearly contradict the patient's known wishes or are not in the patient's interest, consult the ethics committee/legal.

**Legal landmarks:** - **Patient Self-Determination Act (1990):** Federally funded hospitals must ask patients on admission whether they have an advance directive, provide information about them, and not discriminate based on whether one exists. - **Cruzan v. Missouri (1990):** Right to refuse life-sustaining treatment; states may require clear and convincing evidence of an incompetent patient's wishes. - **Quinlan (1976), Schiavo (2005):** Cases about withdrawing life support and surrogate decision-making.

**Clinical pearls:** - Withholding and withdrawing life-sustaining treatment are ethically equivalent. - Artificial nutrition/hydration is considered medical treatment and may be refused. - Encourage advance care planning early (e.g., at diagnosis of serious illness or during routine care). Discussions should include goals of care, and a patient's refusal of one treatment (DNR) does not mean withholding other appropriate care. - Common exam scenario: unconscious patient with a living will and a family member disagreeing, so follow the patient's directive/appointed proxy. Another: patient with a proxy who is not the spouse, so the proxy has priority.