{'fraction_non_alphanumeric': 0.01734390485629336, 'fraction_numerical': 0.0, 'mean_word_length': 5.212307692307692, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
What Should Be Done When a Proxy Is Reluctant to Carry Out the Wishes of an Incompetent Patient?

The following case presents an actual situation that raises a number of important, practical questions. Following our initial presentation of the case in its entirety, we again present the case in stages, along with questions that arise as the case unfolds. Our answers to these questions are not intended to be comprehensive, all inclusive, or irrefutably correct. Rather, we hope that this case study can serve as an educational tool and facilitate discussion among our readers. This particular case raises questions about advance directives and the problems that may arise when patients have documented their wishes. Even when there is a clearly designated proxy, and even when there is a living will, decision making is still a complex process. The case also highlights the problems occasioned by the execution of multiple documents with handwritten notations. With the increased availability and use of advance directives, this situation may be increasingly common. Most important, the case illustrates how situations involving advance directives may vary at different times in the patient’s course of treatment. The case underscores many of the frequently recited key concepts of advance directive education. People should discuss their wishes with their proxies and should choose proxies who will function well under pressure. Whenever possible, care providers should explicitly discuss these considerations with patients before patients select surrogate decision makers. The case can also be used to reflect upon the services within one’s own institution. At what point would a nurse, patient representative, or social worker’s participation be useful? Could an ethics committee have played a role in this situation? Would the hospital’s lawyers or risk management have been helpful participants in the process? We hope that discussion of this case and the questions it raises serves as a valuable teaching tool.