End-of-Life Care & Advance Directives
A board-focused walkthrough of end-of-life ethics built around the core rule that a patient with capacity always decides, with advance directives, surrogate standards, comfort-care principles, and next-best-step vignettes. Covers hospice vs palliative care and brain death vs PVS vs coma.
The One Question That Answers Every Vignette
End-of-life ethics items test a single decision tree: a patient with decision-making capacity may accept or refuse any treatment, and their current wishes override everyone — family, physicians, and even their own written advance directive. Advance directives only "activate" once the patient loses capacity. So on the boards, your first move is always: Does this patient have capacity right now? If yes, honor the choice (even if it leads to death). If no, look for an advance directive — a health care proxy (durable power of attorney) decides on their behalf, guided by what the patient would have wanted (substituted judgment). Refusal of treatment is not suicide, and honoring it is not physician-assisted death. Nail this sequence and most questions solve themselves.
- Decision-making capacity (clinical — any physician can assess) needs 4 elements: (1) communicates a choice, (2) understands the information, (3) appreciates how it applies to their own situation, (4) reasons through the options. Competence is the legal term, decided by a court.
- Capacity is decision-specific and can fluctuate (e.g., delirium, intoxication) — reassess rather than assume permanent loss.
- Living will: written instructions for specific scenarios (e.g., "no intubation if terminally ill").
- Durable power of attorney for health care / health care proxy: names a surrogate; more flexible and broadly useful because it adapts to unforeseen situations — but the agent must still honor any specific instruction in a valid living will.
- Surrogate hierarchy when none is designated (typical order, varies by state): spouse → adult children → parents → adult siblings → other relatives.
- Surrogate standards: use substituted judgment (what the patient would want) when wishes are known; fall back to the best-interest standard only when wishes are unknown.
- A valid advance directive overrides objecting family.
- Vignette: An 82-yo man with metastatic pancreatic cancer becomes obtunded from sepsis. His living will refuses mechanical ventilation; his daughter demands "do everything." → Next step: Do not intubate — the advance directive reflects the patient's own wishes and overrides the family.
- Vignette: A 60-yo woman with pneumonia and full capacity refuses antibiotics after understanding she may die. → Next step: Respect the refusal — a patient with capacity may decline even life-saving therapy.
- Vignette: An unconscious trauma patient has no advance directive and no reachable surrogate and needs emergent surgery. → Next step: Proceed under emergency (implied) consent.
- Vignette: An adult Jehovah's Witness with capacity refuses a life-saving transfusion. → Next step: Honor autonomy — do not transfuse.
- Vignette: A previously capable patient with a proxy is now delirious; the proxy and living will conflict. → Next step: Follow the interpretation that best reflects the patient's known wishes (substituted judgment).
- DNR/DNI limit resuscitation only — antibiotics, comfort measures, and analgesia continue. "DNR" ≠ "do not treat."
- Withholding = withdrawing: stopping a treatment (extubating, discontinuing a feeding tube) is ethically and legally equivalent to never starting it.
- Principle of double effect: escalating opioids to relieve pain/dyspnea in a dying patient is ethical even if it may hasten death, as long as the intent is comfort, not death — do not under-treat pain out of fear of respiratory depression.
- Artificial nutrition/hydration is legally a medical treatment that can be refused or withdrawn (Cruzan).
- *Cruzan*: a state may require clear and convincing evidence of the patient's wishes before withdrawing life support.
- Physician-assisted suicide (physician prescribes, patient self-administers) is legal in a minority of states under strict criteria. Euthanasia (physician administers the lethal agent) is illegal throughout the US.
- Medical futility: physicians are not obligated to provide interventions offering no realistic benefit.
Palliative Care vs Hospice
| Feature | Palliative care | Hospice |
|---|---|---|
| Goal | Symptom & comfort relief | Comfort at end of life |
| Prognosis | Any stage of serious illness | Terminal, ≤6 months |
| Curative treatment | Continued alongside | Forgone |
| Timing | Any time after diagnosis | End of life |
| Certification | Not required | Two physicians certify ≤6-mo prognosis |
| Setting | Any | Home, facility, or inpatient |
- Vignette: A woman with terminal lung cancer has intractable dyspnea; you titrate morphine for comfort knowing it may depress respirations and shorten life. → Principle: Double effect — appropriate; the intent is to relieve suffering.
- Vignette: A ventilated patient has absent brainstem reflexes, no respiratory effort on apnea testing, and a known irreversible cause. → Dx: Brain death = legally dead. The ventilator may be discontinued; family consent is not required to declare death (organ donation is discussed separately).
- Vignette: Four weeks after anoxic brain injury a patient has sleep–wake cycles and eye opening but no awareness or purposeful response; brainstem reflexes intact. → Dx: Persistent vegetative state — alive; decisions follow the advance directive/surrogate.
- Vignette: Family insists on continued ICU care for a brain-dead patient. → Next step: Compassionately explain that the patient is legally deceased; continued organ support is not obligatory.
Brain Death vs PVS vs Coma
| Feature | Brain death | Persistent vegetative state | Coma |
|---|---|---|---|
| Awareness | Absent | Absent | Absent |
| Wakefulness / eye opening | Absent | Present (sleep–wake) | Absent |
| Brainstem reflexes | Absent | Present | Variable |
| Spontaneous breathing | Absent (apnea test +) | Present | Variable |
| Legal status | Dead | Alive | Alive |
Capacity vs Competence — *Clinicians assess Capacity; Courts decide Competence* (all start with C).
4 elements of capacity — "CURA" (a memory aid; Latin for care):
- Communicate a choice
- Understand the information
- Reason through the options
- Appreciate the consequences for your situation
Surrogate standard: patient's wishes Known → substituted Judgment; Unknown → best Interest.
PAS vs euthanasia: Prescribe = physician-assisted suicide (patient acts, legal in some states); Administer = euthanasia (illegal in the US).
Practice Medical Ethics now
Board-style questions, spaced-repetition flashcards, and a Socratic AI tutor — free to start.