Whose best interests? Advance directives and clinical discretion.

A patient's advance directive (AD), confronts a clinician with a quasi-legal document of uncertain status in different jurisdictions and therefore a challenge to her or his clinical acumen and skill. The permutations of factors that need to be taken into account in the resulting clinical decision can be quite confusing. The uncertainties that arise in relation to the provision or otherwise of various forms of invasive and possibly risky clinical treatment can be very disconcerting in that the clinician may be aware of the need to account for the appropriateness of judgments about life-saving treatment and not just the clinical competence that was exhibited. The clinician needs to be clear about the relationships between the duty of care, reasonable medical practice, consent, and what would be considered a substantial benefit or unacceptable risk to the patient. This column outline a decision structure that treats reasonable practice and the patient's wishes as combining to determine whether or not clinical interventions should proceed.