MMHA 6205 Week 2 Advance Directive Dispute Example

"Permanent Unconsciousness" Has Not Yet Been Shown: Who May Apply a Living Will, What Its Words Require and Why a Time-Limited Trial Fits a Day-Two Dispute

Student Name

Walden University

MMHA 6205: Health Law and Ethics

Instructor Name

Month Day, Year

"Permanent Unconsciousness" Has Not Yet Been Shown: Who May Apply a Living Will, What Its Words Require and Why a Time-Limited Trial Fits a Day-Two Dispute

Chronology

Day 1: A 74-year-old woman is admitted through the emergency department after collapsing at home. A CT scan shows a large intracerebral hemorrhage. She is intubated and admitted to the intensive care unit. Day 2: The neurologist tells the family that her prognosis is poor and that meaningful recovery is unlikely, but that a reliable judgment requires several more days of observation. Later on day 2, at a family meeting, her daughter, whom the patient named as health care agent five years ago, asks that the ventilator be removed now under the patient's living will. Her son objects, saying it is too early and that their mother "would want a chance." The family is fictional and appears by role.

The Directive's Operative Clause

The living will states: "If I am in a terminal condition or a state of permanent unconsciousness, as determined by my attending physician and one other physician, I direct that life-prolonging procedures be withheld or withdrawn." The clause has two triggers, each with a certification requirement. The first question is therefore not what the patient would want in general, but whether either condition has been established.

On day 2, neither has. A terminal condition, in most directive statutes, means an incurable and irreversible condition that will result in death within a relatively short time. The patient's condition may prove to be that, but her physicians have not said so. Permanent unconsciousness requires a determination that the loss of consciousness is irreversible, which the neurologist has explicitly declined to make this early. The directive, read by its own terms, does not yet direct withdrawal.

Surrogate Authority

The daughter's authority comes from the appointment. State statutes generally rank a health care agent the patient chose above default surrogates such as adult children, so the son, though he is equally a child, does not share her authority. The Uniform Health-Care Decisions Act, on which several state laws are modeled, follows this pattern: an agent appointed by the patient makes decisions in preference to relatives who would otherwise serve (Uniform Law Commission, 1993).

The agent's authority is not unlimited. She must decide according to the patient's known wishes and, where those are unknown, according to the patient's best interests. She may not substitute her own judgment for her mother's. Here, the patient's wishes are known, and they are conditional: withdrawal if one of two conditions is certified. The agent is bound by that condition as much as the physicians are.

A Supreme Court decision explains why the condition matters. The Court allowed a state to require clear and convincing evidence of the patient's own wishes before ending life support for someone who can no longer speak (Cruzan v. Director, Missouri Department of Health, 1990). A written directive is the strongest form of such evidence. But the evidence it supplies is evidence of a wish to refuse treatment in specified conditions, and it does not extend to conditions the patient did not specify.

What the Team Should Not Do

Two mistakes are tempting. The first is to defer to the agent's request because she holds the appointment. Her authority is real, but it is authority to apply her mother's directive, and the directive's condition has not been met. Withdrawing support now on the agent's word would act on a judgment about permanence that no physician has made. The second mistake is to treat the son's objection as giving him a veto. The son cannot lawfully overrule the agent, and a team that lets the louder relative prevail undermines the patient's choice of decision maker.

The team should also avoid presenting the neurologist's early prognosis as more certain than it is. Families hear "unlikely" as "impossible" or as "possible," depending on what they hope. The neurologist should state plainly what is known now, what will be known in several days and how that information will be gathered.

Ethics

Two standards guide surrogate decisions. Substituted judgment asks what the patient would choose if she could decide; best interests asks what would most benefit her (Beauchamp & Childress, 2019). Substituted judgment applies here because the directive tells us what she would choose, and in what circumstances. The son's argument, that she would want a chance, and the daughter's, that she would not want to live this way, both claim substituted judgment. The directive settles the dispute between them by tying her choice to a medical determination that has not yet been made.

There are real interests on both sides. Keeping her on the ventilator for days she may not have wanted imposes burdens: discomfort, sedation and the possibility of a prolonged death. Withdrawing support before her prognosis is clear risks ending a life she would have wanted to continue. Each sibling is trying to honor her, and the team should say so to both of them, since grief turns disagreements about treatment into disagreements about loyalty.

Resolution

The team should propose a time-limited trial: continued full support for a defined period, with specific endpoints and a plan for what follows. Quill and Holloway (2011) describe such trials as agreements between clinicians and families to use a treatment for a set time to see whether the patient improves according to agreed measures. Here the endpoints come from the directive itself. At the end of seven days, or sooner if her condition declines, the attending physician and the neurologist will examine her and say whether she is in a terminal condition or a state of permanent unconsciousness. If either is certified, the directive applies and the agent will direct withdrawal, with palliative care to keep her comfortable. If neither is certified and she shows signs of recovery, care continues and the family meets again.

The trial respects the agent's authority, since she agrees to it, and the patient's directive, since its conditions decide the outcome. It also gives the son what he asked for, a chance, within limits his mother set. An ethics consultation should be offered to the family, and the meeting and agreed endpoints should be documented in the chart.

References

Beauchamp, T. L., & Childress, J. F. (2019). Principles of biomedical ethics (8th ed.). Oxford University Press.

Cruzan v. Director, Missouri Department of Health, 497 U.S. 261 (1990).

Quill, T. E., & Holloway, R. (2011). Time-limited trials near the end of life. JAMA, 306(13), 1483-1484. https://doi.org/10.1001/jama.2011.1413

Uniform Law Commission. (1993). Uniform Health-Care Decisions Act.