Overriding advance directives: A 20-year legal and ethical overview

Health professionals have been known to override patients' advance directives. The most ethically problematic instances involve a directive's explicitly forbidding the administration of some life-prolonging treatment like resuscitation or intubation with artificial ventilation. Sometimes the code team is unaware of the directive, but in other instances, the override is done knowingly and intentionally with clinicians later pleading that it was done "in the patient's best interests." This article surveys a twenty-year period extending back to 1997 when ethicists began to question the legitimacy of overriding advance directives despite clinicians believing they had compelling reasons to do so. A legal and ethical analysis of advance directive overrides is provided as no court to date has awarded damages to plaintiffs who alleged their loved one suffered "wrongful life" following a successful life-prolonging intervention. A hypothetical scenario is especially discussed wherein a patient's DNR status is overridden because her cardiac arrest was caused by error whose effects might be reversible. The authors conclude with a strategy for mitigating certain vagaries associated with overriding advance directives, but suggest that until courts provide clinicians with clear guidelines and protections, violations of patients' advance directives are likely to continue.

© 2019 American Society for Healthcare Risk Management of the American Hospital Association.

Similar articles

Davies M. Davies M. BMJ. 2009 Nov 26;339:b4693. doi: 10.1136/bmj.b4693. BMJ. 2009. PMID: 19942668 No abstract available.

McLean SA. McLean SA. BMJ. 2009 Nov 26;339:b4695. doi: 10.1136/bmj.b4695. BMJ. 2009. PMID: 19942669 No abstract available.

Buford C. Buford C. Monash Bioeth Rev. 2014 Sep-Dec;32(3-4):217-31. doi: 10.1007/s40592-015-0024-0. Monash Bioeth Rev. 2014. PMID: 25743056

de Boer ME, Hertogh CM, Dröes RM, Jonker C, Eefsting JA. de Boer ME, et al. Int Psychogeriatr. 2010 Mar;22(2):201-8. doi: 10.1017/S1041610209990706. Epub 2009 Aug 10. Int Psychogeriatr. 2010. PMID: 19664311 Review.

Arruda LM, Abreu KPB, Santana LBC, Sales MVC. Arruda LM, et al. Einstein (Sao Paulo). 2019 Oct 10;18:eRW4852. doi: 10.31744/einstein_journal/2020RW4852. eCollection 2020. Einstein (Sao Paulo). 2019. PMID: 31618287 Free PMC article. Review.

Cited by

Stuart RB, Birchfield G, Little TE, Wetstone S, McDermott J. Stuart RB, et al. J Healthc Risk Manag. 2022 Jan;41(3):14-23. doi: 10.1002/jhrm.21487. Epub 2021 Nov 17. J Healthc Risk Manag. 2022. PMID: 34791745 Free PMC article.

References

REFERENCES

    1. Casarett D, Ross L. Overriding a patient's refusal of treatment after an iatrogenic complication. N Engl J Med. 1997;336(26):1908-1910.
    1. Casarett D, Stocking C, Siegler M. Would physicians override a do-not-resuscitate order when a cardiac arrest is iatrogenic? J Gen Int Med. 1999;14(January):35-38.
    1. Hall SA. Overriding a patient's refusal of treatment after an iatrogenic complication [letter to the editor]. N Engl J Med. 1998;337(20):1477.
    1. Pope TM. Legal briefing: New penalties for disregarding advance directives and do-not-resuscitate. J Clin Ethics. 2017;28(1):74-81.
    1. National Academy of Medicine. Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. Washington, DC: National Academies Press; 2015. https://www.nap.edu/read/18748/chapter/1. Accessed May 20, 2019.