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surrogate decision maker (proxy)

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. [13] 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 [2] Management: - in the absence of established goals of care (advance directives) or an available surrogate decision maker, full resuscitation efforts are indicated [17] - framework for resolving advance directives with best interest of patient [7] - 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) [10] - 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 [14] - the effect of physical & cognitive impairment rarely discussed with surrogages - independence & avoidance of burdensome treatments most common issues discussed with surrogates [14] - 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 [3] - providing surrogates with summaries written in easy-to-comprehend language can help with understanding complex medical issues [16] - may be more helpful than providing surrogates access to medical records - does not affect surrogate's anxiety or depression [16] Notes: - details differ between states [11] - JAMA Viewpoint discussing individualized, multifaceted support for surrogates [15]

Related

autonomy competence decision making substituted judgement

Specific

durable power of attorney (DPoA) guardianship

References

  1. Kapp M & Finucane T. Decision Making, In: Comprehensive Geriatric Assessment, Osterweil et al eds, McGraw-Hill, New York, pg 595
  2. White DB et al Are physicians' recommendations to limit life support beneficial or burdensome? Bringing empirical data to the debate. Am J Respir Crit Care Med 2009 Aug 15; 180:320. PMID: 19498057
  3. Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013 - Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022
  4. Vig EK, Starks H, Taylor JS, Hopley EK, Fryer-Edwards K. Surviving surrogate decision-making: what helps and hampers the experience of making medical decisions for others. J Gen Intern Med. 2007 Sep;22(9):1274-9. Epub 2007 Jul 7. PMID: 17619223 - Vig EK, Sudore RL, Berg KM, Fromme EK, Arnold RM. Responding to surrogate requests that seem inconsistent with a patient's living will. J Pain Symptom Manage. 2011 Nov;42(5):777-82. PMID: 22045374
  5. Wendler D, Rid A. Systematic review: the effect on surrogates of making treatment decisions for others. Ann Intern Med. 2011 Mar 1;154(5):336-46. Review. PMID: 21357911
  6. White DB, Malvar G, Karr J, Lo B, Curtis JR. Expanding the paradigm of the physician's role in surrogate decision-making: an empirically derived framework. Crit Care Med. 2010 Mar;38(3):743-50 PMID: 20029347
  7. Smith AK, Lo B, Sudore R. When previously expressed wishes conflict with best interests. JAMA Intern Med. 2013;173(13):1241-1245 PMID: 2371274
  8. Schenker Y, Barnato A. Expanding support for "upstream" surrogate decision making in the hospital. JAMA Intern Med. 2014;174(3):377-379 PMID: 24445360
  9. Shalowitz DI, Garrett-Mayer E, Wendler D. The accuracy of surrogate decision makers: a systematic review. Arch Intern Med. 2006 Mar 13;166(5):493-7. Review. PMID: 16534034
  10. Farrell TW, Widera E, Rosenberg R. AGS Position Statement: Making Medical Treatment Decisions for Unbefriended Older Adults. J Am Geriatrics Soc. Nov 22, 2016 PMID: 27874181 http://onlinelibrary.wiley.com/wol1/doi/10.1111/jgs.14586/full
  11. DeMartino ES et al. Who decides when a patient can't? Statutes on alternate decision makers. N Engl J Med 2017 Apr 13; 376:1478. PMID: 28402767 http://www.nejm.org/doi/10.1056/NEJMms1611497
  12. Caulley L, Gillick MR, Lehmann LS. Substitute Decision Making in End-of-Life Care. N Engl J Med 2018; 378:2339-2341. June 14, 2018 PMID: 29897848 https://www.nejm.org/doi/full/10.1056/NEJMclde1800817
  13. Fried TR, Zenoni M, Iannone L, O'Leary JR. Assessment of surrogates' knowledge of patients' treatment goals and confidence in their ability to make surrogate treatment decisions. JAMA Intern Med 2018 Nov 26 PMID: 30477019 https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2716185
  14. Scheunemann LP, Ernecoff NC, Buddadhumaruk P et al. Clinician-family communication about patients' values and preferences in intensive care units. JAMA Intern Med 2019 Apr 1 PMID: 30933293 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2729390
  15. Dionne-Odom JN, White DB Reconceptualizing How to Support Surrogates Making Medical Decisions for Critically Ill Patients. JAMA. 2021;325(21):2147-2148 PMID: 33988689 https://jamanetwork.com/journals/jama/fullarticle/2780263
  16. Greenberg JA et al. Daily written care summaries for families of critically ill patients: A randomized controlled trial. Crit Care Med 2022 Sep; 50:1296. PMID: 35607975 https://journals.lww.com/ccmjournal/Abstract/2022/09000/Daily_Written_Care_Summaries_for_Families_of.2.aspx
  17. NEJM Knowledge+