## Facts

- Julia K. Warren, age 73, was an incapacitated hospital patient with severe, chronic medical conditions, including prior strokes, advanced vascular disease resulting in bilateral above-knee amputations, and serious infections and ulcers.
- Treating physician testimony described Warren as in a persistent vegetative state and medically fragile, including susceptibility to sepsis and respiratory failure.
- The treating physician recommended a “do not resuscitate” (DNR) order, opining that CPR would not succeed, would require unduly intrusive measures, and carried serious risk of physical trauma.
- A consulting physician concurred that CPR would be unsuccessful, particularly because any cardiac arrest would likely be sepsis-related and not responsive to resuscitation.
- No evidence showed any relevant wishes Warren expressed before losing capacity regarding life-sustaining treatment or CPR.

## Issues

1. Whether a court-appointed guardian has authority under Missouri guardianship law to consent to withholding CPR through a DNR order for an incapacitated ward.
2. Whether a DNR may be authorized when the ward’s prior wishes are unknown but competent, uncontroverted medical evidence shows CPR would be futile and overly burdensome.
3. Whether the trial court erred by treating the medical recommendation as an impermissible “quality-of-life” judgment and by requiring evidence of the ward’s subjective wishes as a prerequisite.

## Decision

- The Missouri Court of Appeals reversed the denial of the guardian’s petition and remanded.
- The court held a guardian may be authorized to consent to a DNR when unrefuted medical evidence establishes CPR would be futile, intrusive, and not in the ward’s best interests, even absent proof of the ward’s prior wishes.
- The court concluded the trial court mischaracterized the medical evidence as “quality-of-life” reasoning and misapplied the governing standard by demanding evidence of Warren’s prior preferences despite medical futility.

## Legal Principles

- A guardian’s statutory power to consent to medical care for an incapacitated ward includes the related power to withhold or refuse medical interventions when medically appropriate and in the ward’s best interests.
- When a ward’s prior wishes are unknown, courts may apply a best-interests standard, with substantial weight given to competent medical testimony regarding futility and burden.
- Withholding CPR may be authorized where reliable medical evidence shows resuscitation has no realistic prospect of success and would impose substantial physical intrusion or harm.
- A clinical judgment that a specific intervention is futile and burdensome is distinct from a subjective assessment of the ward’s “quality of life,” and the former may justify a DNR under judicial oversight.

## Conclusion

The court authorized use of a best-interests, medical-futility framework to permit a guardian to consent to a DNR for an incapacitated ward, rejecting a rule that would require evidence of the ward’s prior wishes even when CPR is shown by uncontroverted medical evidence to be futile and unduly intrusive.


Matter of Warren, 858 S.W.2d 263 (Mo. Ct. App. W.D. 1993)