Nonstandard advance directives: a pseudoethical dilemma.

Critically injured patients occasionally present with indicators that they do not want resuscitation. What should clinicians do if these indicators come to light during resuscitations? This question is explored in the case of an unconscious and unresponsive adult woman with life-threatening injuries from a motor vehicle crash who was wearing a "DNR" medical necklace. The normal use of standard advance directives, including the use of prehospital advance directives, is discussed and contrasted with that of nonstandard directives, including verbal directives. The differing standards required to withhold and withdraw treatments in acutely injured patients are discussed, as are methods for assessing a patient's decision-making capacity at the bedside and a process to rapidly determine ethical courses of action in crisis situations. This discussion emphasizes that patients in life-threatening situations should normally be treated if the only available instructions are nonstandard directives. The patient gives her perspective on why she wore the directive and on the surgeons' actions.