Advance healthcare directive for healthcare professionals and Designated Healthcare Professionals

Orla, a retired woman with severe chronic lung disease and recurrent hospital admissions, makes an advance healthcare directive refusing ventilation to keep her alive in the event of admission to hospital with an exacerbation of her lung condition. She appoints her husband Jim as her designated healthcare representative, including giving him power to advise and interpret her will and preferences for decisions specified in her advance healthcare directive.

A few months later, she is admitted to hospital with pneumonia. She consents to non-invasive ventilation on the ward and, when this is insufficient to relieve her shortness of breath, agrees to full ventilation and admission to the intensive care unit.

A few days after returning home Orla is readmitted to hospital with impaired consciousness due to a recurrent infection and marked worsening of her lung function. She no longer has capacity to decide whether to consent to or refuse ventilation. Orla’s husband and designated healthcare representative Jim provides staff with her advance healthcare directive which states Orla’s wish to refuse ventilation to treat an exacerbation of her lung condition.

Staff are aware that Orla had agreed to ventilation the last time she was admitted. They are concerned that the refusal in her advance healthcare directive may be invalid because it is inconsistent with how she acted when she had capacity.

Staff discuss the matter with Jim. When they explain Orla’s current medical situation to him, he says that even though Orla had accepted ventilation previously, Orla would not wish to be ventilated in the circumstances which have now arisen. On this basis, ventilation is not provided, and Orla dies peacefully shortly after admission. 

Comment: This vignette gives an example of an inconsistent act in operation. Because Orla had capacity at the time of her first admission her advance healthcare directive had no legal effect, but her decision to consent to ventilation was inconsistent with what she had stated in her advance healthcare directive. Ideally, Orla should have been invited to consider her advance healthcare directive in light of her inconsistent act and asked whether she intended her advance healthcare directive to apply to healthcare treatment decisions made after the inconsistent act.

Because this was not made clear, the healthcare professionals here correctly found that Orla’s act invalidated her refusal of ventilation in her advance healthcare directive. However, the vignette also shows that Orla’s will and preference was still the decisive factor with respect to the proposed treatment. As her designated healthcare representative, Jim was able to advise on her will and preferences with reference to her advance healthcare directive in the situation which arose.