Advance directives: navigating conflicts between expressed wishes and best interests.

www.aafp.org/afp Volume 91, Number 7 ◆ April 1, 2015 Case Scenario L.S. is a 70-year-old man with advanced chronic obstructive pulmonary disease. He is intubated and unconscious in the intensive care unit with pneumonia complicated further by acute renal failure. His advance directive, completed seven years ago when he was highly functional, indicates that he wants lifesustaining treatments. He has not updated his advance directive since that time. Members of the medical team are concerned that he has little chance of surviving this hospital stay, and if he were to survive, he is at high risk of significant cognitive deficits that would require long-term skilled nursing care. The patient’s wife is listed as his health care agent in his advance directive. She asks how she should proceed with decision making as she struggles to balance what she thinks would be in her husband’s best interest and what he has indicated in his advance directive.