Designated Healthcare Professionals

Consultation with designated healthcare representative

Tina is admitted to the accident and emergency department with a one-hour history of right-sided limb weakness, and with marked difficulty understanding and producing speech such that she is unable to discuss her care. A brain scan confirms a large recent stroke. Having tried to support and communicate with Tina without success, it is clear that Tina lacks capacity. Her husband Sean is present and has a copy of an advance healthcare directive drawn up by Tina. This includes a statement from Tina that she would not want ‘aggressive measures following a severe stroke’, including resuscitation, ventilation, or tube feeding, even if her life is at risk as a result.

Sean was appointed as his wife’s designated healthcare representative, with the power to advise and interpret her will and preferences, and to consent to or refuse treatment (which explicitly includes decisions relating to life-sustaining treatment) as specified in her advance healthcare directive. Sean explains that his wife’s mother had died in hospital a few weeks after a stroke having received a lot of medical interventions and his wife did not want this to happen to her. 

Dr Browne, the stroke consultant, explains that the circumstances in which the advance healthcare directive is to apply is not entirely clear in her view. For many people, a ‘severe stroke’ refers to the ultimate functional outcome following a stroke, and this is difficult to judge in the immediate period after a stroke. Dr Browne further explains that Tina is within the time frame where she might benefit from thrombolysis, an intervention to dissolve the clot. If this was successful, Tina might have little if any residual consequences of her stroke.

Sean says that he doesn’t know if his wife would have wanted thrombolysis. Having discussed the matter fully with Sean, Dr Browne then obtains a second opinion from her colleague Dr Kelly, a general medicine consultant. Following this, Dr Browne judges that there is still ambiguity regarding Tina’s will and preferences as specified in her advance healthcare directive and that the potentially life- and brain-saving thrombolysis should be given. 

Unfortunately, Tina develops a major brain haemorrhage following thrombolysis. She has impaired consciousness and a dense right-sided stroke. She is unable to communicate. Dr Browne explains to Sean that the likelihood of Tina’s situation improving is now extremely low. Sean states that her current status corresponds to what his wife would have regarded as a severe stroke and that she would not have wanted the specified healthcare treatments in this circumstance. Dr Browne accepts this and ensures that a palliative care approach is put in place.

Comment: This vignette shows the benefits of having a designated healthcare representative to assist in reaching conclusions as to the will and preferences of the directive-maker where there is an ambiguity in the advance healthcare directive. It also demonstrates that the decision of the designated healthcare representative must be in accordance with what they believe to be the will and preferences of the directive-maker, with reference to what has been stated in the advance healthcare directive. The vignette also reflects the dynamic and changing environment in which decisions about healthcare treatment are made and the need for on-going engagement with designated healthcare representatives.   

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