Respecting Patient Autonomy in Medical Decision-Making

Legal and Ethical Framework

The American College of Critical Care Medicine recommends that a patient's directly expressed wishes supersede any surrogate decision-maker's preferences, including those holding durable power of attorney, when the patient has capacity 1
The American Thoracic Society suggests that advance directives serve to codify patient preferences for times when they cannot speak for themselves, but when the patient can actively communicate, their current stated preferences take priority over written advance directives 2, 3

The care team should explain to the relative that the durable power of attorney role only activates when the patient loses capacity, and document clearly that the patient currently has decision-making capacity based on her ability to understand her situation and communicate preferences 1
The American Journal of Respiratory and Critical Care Medicine recommends implementing the patient's wishes, including transferring to ICU and providing vasoactive medications for blood pressure support, as she has consented to 2

The American College of Critical Care Medicine suggests using empathy to acknowledge the relative's distress and desire to help, and explaining that respecting the patient's autonomy is both ethically required and legally mandated 1, 5

The American Journal of Respiratory and Critical Care Medicine recommends documenting the patient's current capacity assessment, including her ability to understand her condition, treatment options, and communicate choices, as well as the patient's specific treatment preferences 2, 4

The American College of Critical Care Medicine warns against deferring to the durable power of attorney when the patient has capacity, as this is a fundamental violation of patient autonomy, and against allowing family pressure to override a competent patient's clearly stated wishes 1

The American Thoracic Society suggests that if the patient's capacity fluctuates or becomes unclear, a formal capacity assessment should be performed, and during periods of incapacity, the durable power of attorney would then have authority to make decisions based on the patient's known values and previously expressed preferences 1, 2, 6