Designated Healthcare Professionals

Designated healthcare representative’s interpretation of the expressed will and preferences with reference to the advance healthcare directive

Danny had a severe stroke due to cardiac disease which has left him with significant disability. He made an advance healthcare directive noting that he does not want life-saving treatment, including treatment with antibiotics, if he is ever seriously unwell and unable to express his own views, even if his life is at risk. He has appointed his nephew as his designated healthcare representative and has given him specific power to advise on his will and preferences as specified in his advance healthcare directive, and to provide or refuse consent on his behalf. Subsequently Danny is admitted to a nursing home, and staff in the nursing home are made aware of the advance healthcare directive.

In the last week, Danny has developed a severe chest infection. At this stage, he is still capable of expressing his own will and preferences, and he declines admission to hospital for antibiotics and rehydration. He agrees to the provision of comfort care including pain relief as needed. He slips gradually into a coma and his nephew reiterates to staff in the nursing home his uncle’s wish to avoid the administration of antibiotics.

Danny’s only child, Laura, lives in Australia and has been informed that he is gravely ill. She has just arrived home to see him in the nursing home. She demands that he immediately commences intravenous fluids and treatment with antibiotics. The nurse in charge tells Laura of her father’s advance healthcare directive. She also tells her that Danny’s nephew is Danny’s designated healthcare representative. Laura protests that she was unaware of the advance healthcare directive and that she is Danny’s closest relative. The nurse in charge states that she is legally obliged to comply with the advance healthcare directive. Danny dies without receiving antibiotics.

Comment: This vignette reflects the tensions that may sometimes arise among families. It also demonstrates the very clear guidance which the Assisted Decision-Making (Capacity) Act 2015 provides in such situations. Absolute priority is given to compliance with a valid and applicable advance healthcare directive and, where a designated healthcare representative has been appointed and given power to advise on the directive-maker’s will and preferences, with reference to the advance healthcare directive, the views of this designated healthcare representative are determinative. The vignette reinforces that it is the will and preference of the person, as expressed in their advance healthcare directive, and not ‘next of kin’ views that determine treatment decisions. A next of kin has no legal status when it comes to healthcare treatment decision-making.

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