Banja John, Sumler Michele
J Healthc Risk Manag. 2019 Oct;39(2):11-18. doi: 10.1002/jhrm.21388. Epub 2019 Aug 21.
Health professionals have been known to override patients' advance directives. The most ethically problematic instances involve a directive's explicitly forbidding the administration of some life-prolonging treatment like resuscitation or intubation with artificial ventilation. Sometimes the code team is unaware of the directive, but in other instances, the override is done knowingly and intentionally with clinicians later pleading that it was done "in the patient's best interests." This article surveys a twenty-year period extending back to 1997 when ethicists began to question the legitimacy of overriding advance directives despite clinicians believing they had compelling reasons to do so. A legal and ethical analysis of advance directive overrides is provided as no court to date has awarded damages to plaintiffs who alleged their loved one suffered "wrongful life" following a successful life-prolonging intervention. A hypothetical scenario is especially discussed wherein a patient's DNR status is overridden because her cardiac arrest was caused by error whose effects might be reversible. The authors conclude with a strategy for mitigating certain vagaries associated with overriding advance directives, but suggest that until courts provide clinicians with clear guidelines and protections, violations of patients' advance directives are likely to continue.
众所周知，医疗专业人员会无视患者的预先指示。在伦理方面最有问题的情况涉及预先指示明确禁止实施某些延长生命的治疗，如复苏或人工通气插管。有时急救团队不知道该指示，但在其他情况下，无视行为是故意且明知故犯的，临床医生后来会辩称这样做是“为了患者的最大利益”。本文考察了从1997年开始的二十年时间，当时伦理学家开始质疑无视预先指示的合法性，尽管临床医生认为他们有令人信服的理由这样做。本文对无视预先指示进行了法律和伦理分析，因为迄今为止，没有任何法院判定向那些声称他们所爱的人在成功的延长生命干预后遭受“错误生命”的原告赔偿损失。文中特别讨论了一个假设情景，即一名患者的“不要复苏”（DNR）状态被无视，因为她的心脏骤停是由可能可逆的错误导致的。作者最后提出了一项减轻与无视预先指示相关的某些不确定性的策略，但指出在法院为临床医生提供明确的指导方针和保护措施之前，违反患者预先指示的情况可能会继续存在。
