Who Decides Who Decides?

Abstract

Advance medical directives are designed to allow a patient to choose a designated agent to make his or her medical decisions should the patient lose decisionmaking capacity. Problems can arise, however, in determining<i>when</i>and if the patient has lost the capacity to make such decisions. We examine a case in which a man with end-stage acquired immunodeficiency syndrome was admitted to the hospital because his agent and family could no longer provide adequate health care at home. While the patient was hospitalized, a conflict about aggressive vs comfort care arose between his physicians and his agent and family, both sides claiming that they knew best what his health care wishes were. At present, there are no clear guidelines as to who evaluates decision-making capacity; therefore, this judgment often falls to psychiatrists or ethics committees or even to the courts. We offer a systematic approach to resolving these conflicts. The