When can you override an advance directive?

An 85-year-old woman with moderate Alzheimer’s disease who enjoys walking in her nursing home’s garden with her walker has fallen and broken her hip. An advance directive signed by the patient states a preference for “comfort measures only,” and specifically states that she does not want to be transferred to the hospital. The physician believes that surgery would provide long-term pain relief and the chance to maintain some mobility.

What do you do? How do you reconcile her previously expressed hypothetical wishes in an advance directive with what is now a rather unanticipated scenario?

In a paper published in JAMA Internal Medicine, a 5-question framework was developed to help physicians and surrogates through the decision making process in time like this. The framework proposes 5 key-questions to untangle these conflicts:

  1. Is the clinical situation an emergency?
  2. In view of the patient’s values and goals, how likely will the benefits of the intervention outweigh the burdens?
  3. How well does the advance directive fit the situation at hand?
  4. How much leeway does the patient provide the surrogate for overriding the advance directive?
  5. How well does the surrogate represent the patient’s best interests?

So, how do the authors balance her previously expressed wishes with that which her surrogate may think is in her best interests?

Based on the framework, the paper argues that it is ethically appropriate for the physician and daughter to override the patient’s previously stated wishes in her advance directive and transfer her to the hospital for surgery.

The situation isn’t an emergency, the benefits of pain relief and quality of life with surgery likely outweigh the harms, the advance directives are not a perfect fit and they also grant the surrogate leeway, and the surrogate represents the patients best interest well.

Eric Widera is an assistant professor of medicine, University of California, San Francisco, who blogs at GeriPal.

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  • usvietnamvet

    This is why it is so important to make sure that the person who is in charge should something happen knows what you would want. If my husband is still alive and capable of making decisions I anticipate few if any problems but we had a hard time choosing which of our kids would be in charge should something happen to one of us and we’re not able to make decisions for the other.

  • keifernny

    I would argue that for an 85 y/o woman diagnosed with Alzheimer Dementia and currently living in a nursing home, the thought of falling and breaking a hip is not an unanticipated scenario and was likely on the forefront of her mind when she conceived these directives.

    I could see necessity for discussion if this were a hypothetical surgery that would reverse progression of her already Moderate Alzheimer Dementia.

    • J.M.

      It depends on when she wrote up her advance directive, and what kind of advice she got.

      When you are 50-60-65 years old and of sound body and mind, filling in an advance directive form for sometime in the inconceivable future, a scenario like this might not have occurred to you.

      How about a 50-yar-old cancer sufferer who has an advance directive, and is responding well to chemo but gets into a car accident on the way home from treatment one morning and ends up with a compound fracture and gushing blood from a femoral artery? Do you think her intention at the time of signing the directive was that she should just be left to bleed out in the street should such a thing happen?

      • keifernny

        In your example, It is the ethical responsibility of the physician (in this case, oncologist) to inform this patient that if she is doing well on her chemo, then it may be time to revise her advance directive if it no longer fits with her wishes.

        She has a legal right to decide whether to actually revise it or not.

        Getting into an automobile accident is an entirely forseeable possibility, and any patient old enough to have a valid advance directive is likely very aware of the possibility (and likely has been personally acquainted with it in some way).

        Your point is valid, however, in that counseling should be provided when an advance directive is written to ensure that people are given accurate information about what the likely outcome of their decision is (and whether they’re aware of the implications in a variety of contexts).

  • maggiebea

    Just because the physician thinks that the benefits of surgery outweigh
    the harms doesn’t mean the patient would agree. If the patient specifies
    ‘don’t put me in the hospital,’ what justifies the physician (who is
    obviously not neutral) overriding that instruction? It’s quite likely,
    indeed, that the longterm result of hip surgery might be relief of pain
    and opportunity for return to mobility … but at what cost? How long
    would the post-surgical period of pain and suffering last? An
    Alzheimer’s patient may not be able to recall that the doctor said ‘only
    six weeks to full pain relief,’ but will certainly suffer every bit of
    frustration and discomfort. In addition to probably being put in
    restraints after the second fall from forgetting that she can’t get out
    of bed. If I write an advance directive saying ‘No Hospital,’ I hope my
    Proxy is smart enough to realize that I mean it.

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