The patient had a living will on the refrigerator at home. Nobody at the hospital knew about it.

A living will specifies the types of medical treatment a person does or does not want if they become incapacitated. A durable power of attorney for health care (DPAHC) designates someone else to make healthcare decisions on the person's behalf. They serve different purposes and can work together - the living will states the patient's wishes while the DPAHC names someone to ensure those wishes are followed.

The Patient Self-Determination Act (42 USC 1395cc(f); 42 CFR 489.102) requires Medicare and Medicaid-participating providers to address advance directives at admission. Specifically, they must ask patients whether they have an advance directive, provide written information about the patient's rights under state law, and document the directive's status in the record. It applies to hospitals, skilled nursing and nursing facilities, home health agencies, hospices, and Medicare Advantage / prepaid health plans (HMOs).

When a patient has no advance directive and no court-appointed guardian or health care agent, state surrogate-consent laws set who decides. The order varies by state, but it commonly starts with the spouse, then adult children, then parents, then the nearest living relative. A court-appointed guardian or a named health care agent takes priority over this default list. The surrogate should decide based on what the patient would have wanted (substituted judgment). This is why advance care planning matters - it prevents difficult family disagreements.