76-year-old man hospitalized with pneumonia
A 76-year-old retired municipal bus mechanic is hospitalized for right middle lobe pneumonia, improving on intravenous ceftriaxone. He has mild Alzheimer disease diagnosed eighteen months ago and brought a pocket radio to the bedside. Vitals are temperature 37.2 C (99.0 F), blood pressure 126/74 mm Hg, heart rate 74/min, and oxygen saturation 96% on room air. On assessment, he demonstrates impaired short-term recall but accurately describes his infection, articulates the mechanics and burdens of cardiopulmonary resuscitation, and consistently requests to remain do-not-resuscitate. His daughter presents a notarized durable power of attorney for healthcare and insists that he receive full cardiopulmonary resuscitation in the event of arrest, stating his dementia diagnosis legally transfers decision-making to her. Which of the following is the most appropriate next step in management?
See the answer and explanation below:
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D
Explanation
Clinical Pearl:
Decision-making capacity is decision-specific and dynamic; an underlying diagnosis of dementia does not automatically invalidate a patient's capacity to choose resuscitation preferences. A durable power of attorney for healthcare is a springing authority that activates only when the patient lacks capacity for the decision at hand.
Explanation:
The patient demonstrates intact decision-making capacity for his resuscitation choice because he understands his pneumonia, articulates the burdens of cardiopulmonary resuscitation, and communicates a consistent, reasoned preference despite his mild Alzheimer disease. Maintaining the do-not-resuscitate order while educating the daughter is the correct action because professional ethics and geriatrics guidance establish that an adult possessing capacity retains decision-making authority, with surrogate powers taking effect only upon incapacity. Changing the orders to full resuscitation to comply with the durable power of attorney document is incorrect because a surrogate cannot override an autonomous patient who currently possesses capacity. Obtaining an urgent psychiatric consultation to establish competence is unnecessary because primary treating clinicians evaluate decision-making capacity, whereas competence is a formal legal determination reserved for courts. Petitioning the court to revoke the daughter's power of attorney is inappropriate because the proxy designation remains legally valid for future instances when the patient may lose capacity. Suspending resuscitation orders pending consensus between the patient and daughter inappropriately compromises the patient's individual autonomy to appease family disagreement.
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