Ask the Bioethicist

Final wish

Illustration: Greg Mably


Question: My father has metastatic lung cancer. The doctors say there is nothing more they can do, and he is now unconscious and ventilator dependent. He is not likely to ever breathe on his own. My father told my brother and me that he would not want to live like this, that he would rather die than be kept alive by machines. But my mom says she can’t let go — that without Dad she will have no life, so she keeps hoping for a miracle and won’t agree to a “Do Not Resuscitate” order or to discontinue life support. What can my brother and I do?

Answer: Ideally the patient decides when to shift the goal of care from cure to comfort.

If a patient can’t do that, we try to find someone who knows what the patient would have wanted. Sometimes finding this person is easy, especially if the patient has established this person’s identity in a legal document granting durable power of attorney.

Usually, however, patients have not created a durable power of attorney. So the treating physician and team take on the responsibility of designating a substitute decision-maker.

If your father is in a Veterans Affairs hospital, the federal rules apply. These use a next-of-kin model, so your mother (his spouse) would be the decision-maker, and you would need to show that she is not abiding by his wishes to invalidate her right to make decisions on behalf of your father. This could be very difficult and divisive. Most states similarly define the appropriate decision-maker as the next of kin (spouse, then adult children, then parents).

If your father is at Stanford Hospital, then he falls under California law, which is quite different from the rest of the country. Our policies call upon the treating physician to designate the surrogate(s) based on who is best able to render a substituted judgment; that is, do what your father would have wanted. A number of criteria must be considered, including the nature of the relationship, knowledge of what the patient would want and the ability to act on the patient’s behalf. The law makes it possible for close friends or gay or lesbian partners to be designated as surrogates over family members if they are best suited to know what the patient would want.

In this case, given that your mom is acting out of her needs rather than what your father would want, and that your father expressed his wishes clearly to you, it would be appropriate for the team to designate you and your brother as surrogates. However, end-of-life decisions like this are never easy, and it would certainly be best if your mom could be brought around to recognize that moving to comfort care would be what your father would have wanted.

I would recommend calling the hospital’s ethics consult service, or someone from the spiritual care service if your mother is religious. Together with the team they might be able to help make it clearer to her that the goal is to do what your father would have wanted and help her to come to terms with what is happening. It may take a little time, but in the long run that would be better than permanently jeopardizing your relationship.

David Magnus, PhD, directs the Stanford Center for Biomedical Ethics. Send your questions to or Ask the Bioethicist, Stanford Center for Biomedical Ethics, 701 Welch Road, Suite 1105, Palo Alto, CA 94304

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