The surrogate decision-maker's understanding of this patient's medical condition and previously expressed health care wishes and values should be evaluated. For the patient who lacks decision-making capacity, the surrogate decision-maker should not make decisions based on his or her own values and preferences. Rather, the surrogate has ethical and legal obligations to make decisions that are based on the patient's health care values, goals, and preferences (the concept of substituted judgment). If these values, goals, and preferences are unknown, the surrogate should make decisions based on what he or she considers to be the best interests of the patient. In this case, the patient's daughter may think that the patient's prognosis is poor and may be acting based on that misconception. The patient's daughter should be engaged in a discussion to evaluate her understanding of the patient's condition and to clarify the patient's health care preferences in order to ensure that the decision is consistent with the patient's previously expressed wishes.

Obtaining a court-appointed guardian is not indicated in this case in which the patient clearly stated her views in her advance directive and subsequent care decisions will be made by a duly appointed surrogate based on the patient's wishes. The most appropriate approach is to explore the daughter's understanding of her mother's medical condition as well as her understanding of her mother's previously expressed health care wishes and values.

The patient's daughter's refusal of further treatment should not be summarily accepted. Rather, the physician should determine the daughter's understanding of the proposed treatment plan and suggest a treatment recommendation that does not conflict with the patient's previously expressed wishes. If the surrogate's decisions seem inconsistent with the patient's values or previous directives, the clinician should proceed with extreme caution. Ethics consultations are helpful in reconciling these conflicts.