NONSTANDARD ADVANCE DIRECTIVES - A PSEUDOETHICAL DILEMMA

Critically injured patients occasionally present with indicators that they do not want resuscitation, What should clinicians do if these ind icators come to light during resuscitations? This question is explored in the case of an unconscious and unresponsive adult woman with life- threatening injuries from a motor vehicle crash who was wearing a ''DN R'' medical necklace. The normal use of standard advance directives, i ncluding the use of prehospital advance directives, is discussed and c ontrasted with that of nonstandard directives, including verbal direct ives, The differing standards required to withhold and withdraw treatm ents in acutely injured patients are discussed, as are methods for ass essing a patient's decision-making capacity at the bedside and a proce ss to rapidly determine ethical courses of action in crisis situations , This discussion emphasizes that patients in life-threatening situati ons should normally be treated if the only available instructions are nonstandard directives, The patient gives her perspective on why she w ore the directive and on the surgeons' actions.