Mrs. Douglas has refused to consent to surgery for her husband. This decision is not based on the best interests standard, since it is in the interest of Mr. Douglas's survival to have cardiac surgery. Mrs. Douglas claims to be using the "substituted judgment" standard, offering the decision her husband reached earlier in the course of his illness when he did not believe he would have a heart attack and didn't want to take time out from his work for the surgery. This may not be the decision Mr. Douglas would make now because he cannot continue with his business unless he has surgery. Accordingly, the preferable course of action is option B—continuing to recommend surgery to Mrs. Douglas. Pursuing this option will likely uncover any other reasons Mrs. Douglas may have for making this decision.
If Mrs. Douglas continues to reject surgery because Mr. Douglas had previously refused and she does not provide further explanation, option A (getting a court-appointed guardian) is an acceptable option. Although involving the courts should be avoided if possible, if Mrs. Douglas makes her decisions without sound basis in substituted judgment or the best interests standard, the physicians have an obligation to try to find another surrogate.
Options C (prepping Mr. Douglas for surgery) and D (treating Mr. Douglas without surgery) should be avoided. So long as Mrs. Douglas refuses and the courts do not appoint an additional guardian, prepping Mr. Douglas for surgery fails to respect Mrs. Douglas as the legitimate surrogate decision maker. The poor prognosis of option D indicates that it too should be avoided. If Mrs. Douglas remains the legal decision maker and she requests a treatment, however, this treatment may offer Mr. Douglas some chance of survival.
Preferable: Option B
Acceptable: Option A
Avoid: Options C and D