## Facts

- Russell R. Border, Jr. executed an advance directive combining a health-care power of attorney and a living will.
- The directive named Border’s daughter as health-care agent, stated a general preference for life-sustaining treatment “in all situations,” and also stated his instructions were “guides” not to be applied strictly.
- The directive authorized the agent to withhold life-sustaining treatment if doing so was in Border’s best interests.
- After Border’s condition deteriorated, an orphans’ court initially appointed the daughter as guardian but later removed her, revoked the power of attorney, and appointed attorney Sharon L. Gray as plenary guardian of Border’s person.
- Border later suffered multiple organ failure, ventilator dependence, severe infected wounds, and persistent pain that could not be adequately treated due to respiratory compromise.
- Treating physicians testified Border’s condition was terminal and further life-prolonging treatment was medically futile and would prolong suffering.
- Despite incapacity, Border communicated to family that he wanted to be allowed to die.
- Gray refused to authorize withdrawal of life-sustaining treatment, asserting the living will required continued treatment in all circumstances.
- The hospital petitioned to remove Gray and appoint Border’s brother as successor guardian with authority to make end-of-life decisions.
- After an evidentiary hearing, the orphans’ court removed Gray, appointed the brother, and authorized withdrawal of life-sustaining treatment; Border died shortly after treatment was withdrawn.
- Gray appealed.

## Issues

1. Whether the advance directive, read as a whole, required continued life-sustaining treatment despite medical futility and evidence of Border’s suffering and contemporaneous wishes.
2. Whether a guardian of the person must apply a best-interests and known-wishes framework, rather than a strictly literal reading of a single clause in a living will.
3. Whether the orphans’ court abused its discretion or erred as a matter of law in removing Gray and appointing a successor guardian to consent to withdrawal of life-sustaining treatment.

## Decision

- The Superior Court of Pennsylvania affirmed the orphans’ court’s order.
- The court held the advance directive did not mandate continued life-sustaining treatment under all circumstances; its best-interests language and “guide” language required a contextual reading.
- The court held the orphans’ court properly relied on medical evidence of terminal condition, futility, and unrelenting suffering, along with evidence of Border’s expressed wish to die.
- The court held the orphans’ court did not abuse its discretion in removing Gray where her refusal to consider best interests and known wishes conflicted with the ward’s welfare and intent.
- The court upheld appointment of Border’s brother as successor guardian with authority to consent to withdrawal of life-sustaining treatment.

## Legal Principles

- Advance directives must be construed as a whole; general pro-treatment language does not control when the instrument also grants discretion tied to best interests and indicates instructions are not to be applied rigidly.
- A guardian of the person must make health-care decisions consistent with the incapacitated person’s known values and wishes when ascertainable, and otherwise according to the person’s best interests.
- Best-interests analysis may include prognosis, medical futility, burdens of treatment, pain and suffering, and credible evidence of the person’s current expressed preferences.
- A court may remove a guardian when the guardian’s decisionmaking departs from the incapacitated person’s intent and best interests, including where the guardian applies an inflexible interpretation that prevents appropriate medical decisions.
- Guardianship is an office exercised for the ward’s benefit; it is not an entitlement of the guardian.

## Conclusion

The court affirmed that end-of-life decisionmaking for an incapacitated person must follow the person’s advance directive as an integrated document and must account for best interests and known wishes; where a guardian refused to do so and insisted on continued futile treatment, removal and replacement of the guardian and authorization to withdraw life-sustaining treatment were proper.


In re Estate & Person of Border, 68 A.3d 946 (Pa. Super. Ct. 2013)