surrogate decision maker (proxy)

Introduction

A person designated to make decisions for a patient that has lost autonomy.

This generally defaults to a family member, but is state specific.

The surrogate does not need to be a legally married spouse.

Next in line are generally children, parents, siblings, grandparent, grandchild.

A health care proxy is a written document in which the patient designates a person to make health care decisions on his or her behalf if he or she no longer has capacity to make health care decisions.

The document does not specify preferences for medical care.

The health care proxy becomes the first person in the hierarchy of surrogates.

A surrogate must use one of 2 standards for decision-making:

• substituted judgment
• best interest

Ideally, a surrogate uses substituted judgment to infer from a patient's earlier statements or actions, what choices that person would now make if he/she was still able to express an autonomous decision.

In practice, surrogates often guess incorrectly or substitute their own beliefs for those of the patient; yet confidence in their substituted judgement seems high.

The surrogate must act in the patient's best interest.

The physician must serve as the patient advocate.

No consensus among surrogates for or against physician recommendation regarding life support decisions for incapacitated patients; 42% of surrogates prefer no physician recommendations

Management

• in the absence of established goals of care (advance directives) or an available surrogate decision maker, full resuscitation efforts are indicated
• framework for resolving advance directives with best interest of patient
  • is this an emergency?
  • considering the patient's values & goals, how likely is it that the benefit of an intervention will outweigh the burden?
  • does the advance directive fit the current situation?
  • how much liberty did the patient provide the surrogate for overriding the advance directive?
  • does the surrogate represent the patient's best interests?
• when the patient does not have a surrogate decision maker, (unbefriended patient) consider nontraditional surrogates (close friend, neighbor, clergy member)
  • medical decisions based on team consensus (at least 2 attending physicians plus surrogates) are preferred over decisions made by one person
  • if all else fails. use substituted judgement
• failure to ask a surrogate to use substituted judgement to aid in a decision is common
• the effect of physical & cognitive impairment rarely discussed with surrogages
• independence & avoidance of burdensome treatments most common issues discussed with surrogates
• when there is apparent conflict between the requests of a surrogate decision maker & the patient's advance directives, meet formally with the surrogate decision-maker, family members, & the health care team to discuss prognosis, treatment options & the patient's values
• providing surrogates with summaries written in easy-to-comprehend language can help with understanding complex medical issues
  • may be more helpful than providing surrogates access to medical records
  • does not affect surrogate's anxiety or depression

Notes

• details differ between states
• JAMA Viewpoint discussing individualized, multifaceted support for surrogates

More specific terms

• durable power of attorney (DPoA)
• guardianship

Additional terms

• autonomy
• competence
• decision making
• substituted judgement