A patient who has suffered a stroke is aphasic and unable to swallow.

Under Health Care Risk Management principles supported by ASHRM and the American Hospital Association Certification Center, patient autonomy is upheld by honoring valid advance directives and durable powers of attorney for healthcare. When multiple documents are presented that designate different decision makers, the most recent properly executed document typically supersedes earlier versions, unless state law provides otherwise.

Durable powers of attorney for healthcare may be revoked or replaced by executing a newer document. Therefore, determining the effective document requires reviewing execution dates and ensuring validity under applicable state statutes, including witnessing and notarization requirements. The document with the more recent date generally reflects the patient’s latest expressed wishes and controls decision-making authority.

Referring immediately to an ethics committee may be appropriate in unresolved value conflicts, but first establishing legal authority is essential. Asking the family to resolve the dispute independently delays necessary medical decisions and does not clarify legal standing. Selecting the older document would contradict the principle that later directives replace earlier ones.

Legal and regulatory objectives emphasize verification of surrogate authority, compliance with state advance directive laws, and protection of patient autonomy. Therefore, the risk manager should confirm which document is most recent and legally valid.