Two Decision-Makers, One Patient
You are called to an 84-year-old woman in a long-term care home who fell during a transfer. She has advanced dementia, is moaning, and cannot answer questions. Her right hip is shortened and externally rotated. HR 112, BP 102/64, SpO2 94%, capillary refill 3 seconds. A chart at the bedside reads: 'Goals of Care: Comfort Care. Do Not Transfer to Acute Care. No CPR,' signed by her physician two months ago. The night nurse says, 'She's comfort only.' Her daughter calls and says, 'My mother would want everything done. I'm her POA and I'm telling you to take her in.' Her son, also listed as POA, is unreachable.
1. What framework governs this decision, and what do you actually do on scene while it is unresolved?
Read the worked answer
There are three competing sources of authority and I name them out loud:
- A written goals-of-care directive signed by her physician: comfort care, no transfer, no CPR.
- A substitute decision-maker (daughter, POA) demanding full treatment.
- The patient, who cannot express wishes now.
Provinces differ on whether a valid written directive outranks an SDM, and on whether an SDM can override one. I do not have to resolve that in a bedroom - but I must not guess at it either.
Practical sequence:
- Treat what is unambiguous: analgesia, gentle handling and splinting, warmth, positioning, monitoring. Comfort care is still care, and it is not the same as no care.
- Verify the document - current, correctly named, applicable to this event, and check whether a newer plan exists elsewhere in the chart.
- Patch to base hospital and describe the conflict. Ask for a physician decision and document who said what, and when.
- If no decision is available and she is unstable, err toward treatment and transport. You can always stop treatment; you cannot undo a death.
The default under genuine uncertainty is not 'do nothing because there is a form.'
2. How do you structure the phone conversation with the daughter? What do you say first, and what do you avoid?
Read the worked answer
- Identify and verify - full name, relationship, whether she is the legal SDM, and the best number to reach her.
- Ask before telling: 'What did your mother say, when she could still say it, about being in hospital?' That is the question that actually matters, and it belongs to the family, not to me.
- Describe plainly what I see: a probable hip fracture, stable but uncomfortable vitals, and what I can and cannot do in a care home.
- Be transparent about the chart. She may not know it exists, or she may dispute it. I read her the exact wording rather than characterising it.
- Offer a real bridge - put the base hospital physician on the phone with her, or point her to the facility's medical director.
- Document verbatim quotes and times.
What I avoid: delivering 'your mother has a do-not-transfer order' as a verdict. She has just been told by a stranger that her mother is hurt. She needs facts and a next step, not a ruling.
3. The daughter remains insistent, and the base hospital physician tells you to follow the chart. What does that mean in practice?
Read the worked answer
I follow the physician's direction - it is a documented, licensed decision - but 'follow the chart' is not 'do nothing'.
- Comfort measures continue: analgesia per protocol, careful handling, pressure-area protection, warmth, reassurance, positioning.
- Re-read the exact wording. Many comfort-care orders exclude CPR and ICU but not oxygen or analgesia. I check whether the directive even addresses airway management before withholding something it never mentioned.
- Close the loop with the daughter: who made the decision, on what basis, and how she can challenge it (facility medical director, patient ombudsman, provincial process). Handing someone a route reduces the chance of a confrontation at the bedside.
- Document the conflict itself, not just the outcome, and file a report if I believe the directive and the patient's interests genuinely diverge.
- If she decompensates in a way the directive does not clearly cover, I treat and I patch again - stating on the recording why I am departing from the plan.
'Follow the chart' is a decision, not an instruction to stop thinking.