Cifu: "A patient, dealing with illness, in a completely foreign situation, often needs assistance articulating and applying his or her values and wishes."

Nailed it. There is a meaningful distinction between informed consent ("assent" in this exchange) and paternalism. In this particular case...

1. Dr. Z knew his patient and her values; a relatively rare thing for hospital-based physicians. 2. After offering his recommendations he still queried her wishes ("Is that alright?") and was presumably willing to honor them, even if she opted for a more aggressive course of treatment. 3. He talked with her post-hospitalization since patient wishes are often impacted by ICU stays.

Thank you for sharing this case and your humility/beginner's mind.