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When the Patient without Capacity Objects to Implementing Her Advance Directive

Posted Feb 02 2009 11:43pm
Advance directives are often referred to as the gold-standard form of guidance for determining an incapacitated patient's end-of-life treatment.  "If she only had an advance directive, then we would just do what it says."  Of course that logic is often not so easy to apply.  Either the advance directive cannot be found.  Even if it can be found, it is often unclear how it applies to the present clinical circumstances.  
But assume that the advance directive has been completed, is available, and can be interpreted.  Should it always be followed?  The answer is generally "yes."  But there is an important fuzzy exception.
The advance directive is not relevant unless or until the patient loses capacity.  Once the patient loses capacity, she cannot "revoke" her advance directive.  But she can still "object" to its implementation.  This is an indication that we have not quite settled the personal identity questions surrounding advance directives.  But even if we are going to disallow Patient at T1 to control the health care decisions of patient at T2, exactly how much are we going to require from Patient T2 to rebut Patient T1's choices?
That is addressed in a  story in theDaily Mailthis week.  "Many people are now writing living wills, setting out their treatment preferences in case they later become too ill to express their wishes. But what if they change their mind, yet are unable to communicate this?"  The son of Lilamani Kapoor writes how he did the right thing by ignoring her advance directive.

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