Advance Care Planning Conflict Between Daughter and Patient
Mr. T is 78 with advanced heart failure (NYHA III-IV, ejection fraction 25%) and stage 4 chronic kidney disease. He has capacity. He tells you he does not want CPR or intubation and wants to focus on comfort at home. His daughter, who is his main caregiver and holds his power of attorney for property, insists 'everything be done' and threatens to report you. She has not been told his wishes directly. He becomes tearful and says 'I don't want to upset her.' His medications include sacubitril/valsartan, carvedilol, spironolactone, and furosemide; his most recent potassium is 5.6 mmol/L and creatinine 210 micromol/L. He has had two admissions in 3 months for decompensated heart failure.
1. How do you handle the conflict between the patient's stated wishes and his daughter's demands?
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Capacity is the anchor. Mr. T has capacity and his wishes govern; the power of attorney for property does not override his personal care decisions while he has capacity, and a substitute decision-maker only acts when he lacks capacity. My role is to ensure his wishes are documented and communicated, not to let the loudest voice decide.
Process:
- Confirm and document capacity and his wishes in his own words, including what he understands about CPR and intubation and the alternatives.
- Explore his reticence: he fears upsetting his daughter. Offer to facilitate the conversation with him present, or to speak with her with his permission.
- Meet the daughter with curiosity, not defensiveness. Acknowledge her fear and burden. Ask what she is most worried about ('that I will lose him' or 'that I will be blamed').
- Explain what CPR and intubation would realistically mean for him given his heart failure and kidney disease (low likelihood of survival to discharge, high likelihood of prolonged ICU stay and suffering).
- Reassure her that choosing comfort is not abandoning him and that she will be supported.
- Document the discussion, complete a goals-of-care and CPR form, and share with the team and community services.
If conflict persists, involve the palliative care team or ethics consultation, and continue to support the daughter.
2. His potassium is 5.6 mmol/L and he is on sacubitril/valsartan and spironolactone. How does this interact with his goals?
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This is a concrete example of how comfort-focused goals change medical management. With NYHA III-IV heart failure, eGFR-relevant CKD, and a potassium of 5.6, continuing both sacubitril/valsartan and spironolactone risks hyperkalemia and arrhythmia. The question is not only 'what does the guideline say' but 'what serves his stated goal of comfort at home and avoiding hospitalization.'
Reasonable steps:
- Stop spironolactone now; it is the most potassium-sparing agent and offers little short-term symptomatic benefit at this stage.
- Reduce or hold sacubitril/valsartan; these agents have mortality benefit but if they cause hyperkalemia, hypotension, or repeated admissions, deprescribing may better serve comfort.
- Continue furosemide for symptom control, with monitoring for hypotension and renal function.
- Consider a low-potassium diet and, if needed, a potassium binder, but weigh pill burden against comfort.
- Discuss with him and his daughter that we are shifting from 'live longer' to 'feel better,' and that stopping some medicines is part of that plan, not a withdrawal of care.
- Document the rationale and a plan for what to do if he deteriorates (e.g., home symptom management, avoid hospitalization unless he chooses).