Surrogate Decision Making 11-10-14 Flashcards
What is the purpose of surogates?
When the patient lacks capacity, the surrogate is empowered to make decisions for the patient according to certain standards
Surrogates rarely make decisions alone and should be encouraged to develop consensus between interested individuals
Usually family members serve as surrogates, but, sometimes conflicts cause impaired decision making
What if decisions made by surrogates don’t appear to be in the patient’s best interest?
Physician should serve as patient’s advocate if surrogate decisions don’t appear to be in patient’s interest
What is the hierarchy of surrogates?
Usually defined by state statute
In Colorado, “Proxy by statute”
In New York, hierarchy defined as 1.)spouse or domestic partner, 2.)children, 3.)parents, 4.)siblings and 5.)close friends (in absence of POA or court-appointed guardian)—this hierarchy may be problematic in certain instances
What if there is no proxy or POA named?
If no proxy or POA named and patient has no one to act as surrogate, physician should make decisions that they believe are in the patient’s best interests
What is substituted judgment?
Explicit expression of patient’s preferences prior to incapacity, may be verbal or written
Inferred knowledge of patient’s preferences from statements or life values
What is a good description for best interests?
Vague and debatable, but best described as “looking at the world through the eyes of the patient”
What are some limitations of surrogates and their decisions?
Surrogate incapacity or death
Surrogate may choose to make decisions according to their own values
Surrogates may experience emotional barriers to decision making
Conflicts of interest
Parental limitations in making surrogate decisions for their children
What are some things that parents must do in order to be surrogate decision makers for their children?
Must be competent and have decisional capacity
Wide latitude in decisions, but must be in child’s “best interests”
Decisions may not harm the child
Wide range of scenarios
High-risk, low reward interventions
Little-risk, high reward interventions
Physician has the obligation to intervene at times
What is a technique for improving surrogate decisions?
Family meeting:
Remind participants that decisions should be made according to patient’s wishes and values
Acknowledge difficulty of decision making
Review patient’s medical situation
Make recommendation
Explore sources of conflict among participants
Involve other health care workers, ethics committee, or professional mediator, if appropriate and time allows
What is the purpose of advance care planning? How is it done?
Thoughtful, reflective planning for medical care in the event of future incapacity
Extends patient’s autonomy into the period of incapacity
An opportunity for patients to explore their values, beliefs and attitudes about quality of life and preparation for death
Ideally occurs in consultation with loved ones, spiritual advisors and physician
Allows physicians and surrogate decision makers to make decisions consistent with patient’s values
Provides surrogates with detailed knowledge of patient’s values and helps to avoid family conflicts
What is an advanced directive? What does it often include?
A written or verbal statement directing treatment preferences in event of decisional incapacity
Usually names a proxy (durable POA for health care)
Often includes instructional directives (living will), ie. specified treatments that the patient would or would not want in specific situations
Sometimes general, eg. “heroic measures” and sometimes specific, eg. Hydration, feeding tube, ventilatory support.
Ethically supported by concept of patient autonomy
Legally recognized in all states
Takes various forms depending on the state
What are some objections to advanced directives?
Terms may be vague and subject to interpretation
Difficult to predict and describe every possible clinical scenario
Patient may not understand the clinical situations and/or interventions
Patient may change their mind
Patient is no longer the same person once they become incapacitated
What are some limitations of advanced directives?
Often created in estate planning discussions with attorneys . Doctors and/or spiritual advisors aren’t involved
Time constraints, lack of reimbursement and reluctance to discuss end-of-life issues may impede physician from mentioning advance directives
Often not available or accessible by physician when needed, or healthcare workers may not know that they exist
Sometimes created in situational crisis in hospital
Patient Self-Determination Act (1990)
Attending physician in hospital may not be patient’s usual physician
Usually still requires some judgment on part of surrogate decision maker(s)
What are some benefits of advanced directives?
In spite of limitations, advance directives give the patient some autonomy in decision making
With good advance care planning, physicians will have better knowledge and understanding of patient’s values and preferences, and will be better able to promote good decisions (beneficence) and avoid harmful interventions (non-maleficence)
With good advance care planning, physicians can help educate patients about contextual issues and deal with disagreements among family members
If a patient makes an informed refusal of your care, what do you do?
Honor their wishes
