The suspicion that a patient's change of heart does not represent his considered judgment is very problematic. In the emergency setting, limitation of care generally requires greater certainty than proceeding with aggressive care. In this case, the appropriate action is to accept Mr. S's request for aggressive therapy. Advance directives should be understood as an ongoing discussion and not as an event that yields a finished product. There are strategies that families can employ to promote more effective advance directives.
Most deaths occur from predictable complications of chronic illnesses.
Families should discuss these complications in detail and, where possible, ask physicians to provide quantitative estimates of risks and probable survival. For their part, physicians should encourage a patient to ask questions, to make sure that the patient does not have unrealistic expectations. If there is any difficulty in communication between the health care team and the family, then it may help to take advantage of the services of a facilitator. A facilitator can be of tremendous value because he or she often has the skill and the time to communicate directly with all the parties involved. There is an expanded discussion of the case in Critical Care Pearls, 2nd Ed.