At end of life, when a patient lacks decision-making capacity and has no durable power of attorney, which principle guides nursing action?

• A. Immediately follow the physician's directive
• B. Respect the patient's previously stated preferences if known
• C. Seek court appointment for surrogate decision-making
• D. Proceed with standard treatment

Answer: (B)

Honoring the patient’s previously stated preferences guides nursing action. When someone can no longer decide and there is no durable power of attorney, the nurse should follow any known wishes the patient expressed about treatment goals, resuscitation, and interventions. These prior directives—whether in an advance directive, living will, or documented conversations about goals of care—reflect the patient’s values and what they would have chosen for quality of life at the end of life. Implementing those preferences ensures care remains person-centered and respects autonomy, even without decision-making capacity.

If those preferences are known, they should be documented, communicated to the team, and used to shape the care plan, often prioritizing comfort and dignity if that aligns with the patient’s goals. If no preferences are known, then the next steps involve seeking a surrogate decision-maker or applying a best-interest standard to determine what would most support the patient’s well-being, rather than automatically following a physician’s directive or defaulting to standard treatments that may not reflect the patient’s values.