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Informed refusal — USMLE Step 3 MCQ

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HardEthics, Patient Safety, Quality Improvement, Systems-Based PracticeInformed refusalUSMLE Step 3

A 67-year-old woman with advanced ovarian cancer lacks decision-making capacity because of septic encephalopathy. She has a valid advance directive refusing intubation and major surgery if cancer is no longer curable. Bowel perforation is diagnosed; surgery would require prolonged ventilation and is unlikely to restore meaningful survival. Her son requests every intervention. Which response is most appropriate?

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Correct answer: C — Follow the directive and provide nonoperative and comfort-focused treatment

The best answer is “Follow the directive and provide nonoperative and comfort-focused treatment”. When capacity is lost, a valid advance directive is the patient’s own decision and governs care in the circumstances it addresses. A surrogate interprets preferences when they are unknown; the surrogate does not acquire authority to contradict a clear refusal.

Reference: AMA Code of Medical Ethics: Advance Directives: https://code-medical-ethics.ama-assn.org/ethics-opinions/advance-directives