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Surrogate decision maker

What Is A Surrogate Decision-Maker?

A surrogate decision-maker (SDM) is a person that makes healthcare decisions based on the understanding of the patient’s values and preferences. A study published in the Nursing Outlook journal defines surrogate decision-makers as typically family members who are entrusted with the authority of making healthcare decisions on behalf of their sick loved ones who lack capacity. Their sick loved ones who lacks decision-making capacity are like those who are dying in the intensive care unit (ICU) because of chronic disease like heart disease. The study adds that surrogate decision-makers or surrogates are expected to make healthcare decisions that are approximate as closely as possible to the choices their family members with terminal illness would have made if they were able.

Surrogate Decision-Maker Hierarchy

A study published in the Continuum journal of the American Academy of Neurology explains the surrogate decision-maker hierarchy. The surrogate decision-maker hierarchy guidelines are provided by most states in the United States in the event that the patient is not able to assign a designated healthcare proxy in advance. The first in the surrogate decision-market hierarchy is the spouse. The next in the hierarchy are adult person. Next to the adult person are additional family members. The state laws determine the limits on the types of decisions that can be made by surrogate decision-makers. These limits may vary from state to state.

The study also mentions the hierarchy of standards pertaining to healthcare decisions made on behalf of a patient who lacks decision-making capacity. The highest priority is given to enacting the patient’s previously expressed wishes for end-of-life care, advance care planning, or other medical care through written documents such as living wills and advance directives. In the absence of written documents, a verbal statement can be used. The next in the hierarchy of standards is based on the principle of substituted judgment or through a surrogate decision-maker. Lastly, if there is no presence of the patient’s preferences and values available, health care decisions must be made in accordance with the best interest standard. The best interest standard is looking at the risks and benefits of a treatment and making health care decisions according to how a reasonable person would be expected to weigh in those risks and benefits.

What Does A Surrogate Decision-Maker Do?

A surrogate decision-maker makes healthcare decisions on behalf of an individual patient who lacks decision-making capacity (DMC). The healthcare decisions that surrogate decision-makers make are based on what the incapacitated patient would have wanted. If the patient lacks documentation of the patient’s preferences for care, the surrogate decision-makers are also tasked to decide on the best interest or what they believe is best at that time. Lastly, surrogate decision-makers must still pursue to involve the incapacitated patient in the surrogate decision-making process together with the patient’s medical people.

Medical Implications Of Surrogate Decision Maker

There are several medical implications of surrogate decision-makers for health care providers or medical people. The first medical implication is making decisions on whether to remove or limit life-sustaining treatments. Removing or limiting life-sustaining treatments can be difficult for surrogate decision-makers if they lack the knowledge pertaining to the patient’s preferences and wishes. Communicating with healthcare providers can still be inadequate which leaves surrogate decision-makers without the critical information that they need whether to initiate or continue life-sustaining treatments.

Another medical implication of surrogate decision-makers for health care providers like primary physicians is when significant medical uncertainty exists. Medical uncertainty includes different outcomes such as patient death, chances for persistent cognitive or functional disability, low chances of a return to previous functional status, and alternatives to medical or life-sustaining treatments. These circumstances may not have been explained to surrogate decision-makers thoroughly, so they may be forced to rely on suppositions and projections based on their own experience, information, hearsay, and fears. Medical practitioners and primary physicians may also have difficulty communicating complex medical information with surrogate decision-makers. This could also create conflicts when surrogate decision-makers make health care decisions that are incompatible with the health care provider’s own judgment.

Surrogate Decision-Maker Laws

A study published in the New England Journal of Medicine tackles surrogate decision-maker laws. There are surrogate decision-maker laws for all 50 states and the District of Columbia. These laws may have different terminologies in discussing alternate decision-makers such as court-appointed, patient-designated, or default.

Surrogate decision-makers have an obligation to follow the expressed wishes of the incapacitated person and make health care decisions based on the patient’s values. The patient’s health care providers are also required to honor the patient’s wishes and values. In the event the patient’s wishes or values are not expressed, surrogate decision-makers must be guided by the patient’s best interests.

Surrogate decision-makers are responsible for getting all the facts from health care providers about the diagnosis, prognosis, and alternative treatments for the patient. When facing critical treatment decisions, surrogate decision-makers should ask themselves the following questions:

  • Will this treatment or test make a difference to the patient’s condition? How?
  • Do the burdens or risks of this treatment outweigh the benefits for the patient?
  • Is there hope of recovery, and, if so, what will life be like for the patient afterward?
  • What is the goal of this life-sustaining treatment? Is it aligned with the patient’s goals?

Criteria For Being A Surrogate Decision-Maker

A study published in the New England Journal of Medicine focused on the criteria for being a surrogate decision-maker. The first criterion is age. The study mentions that all states require surrogate decision-makers to be adult individuals. However, some states have different definitions of adulthood from 18 years up to 21 years.

The next criterion measures the hierarchy based on the relationship to the patient. The surrogate hierarchy ranks the spouse, the child, and the parent as the highest-priority classes. Some states recognize institutional mechanisms for surrongate decision-making, such as appointing a physician, a group of physicians, a social worker, or a hospital ethics committee.

The next criterion defines how the surrogate decision-maker must be willing to act, reasonably available, and able to engage in complex medical decision-making. This criterion has limitations in measuring the degree of willingness to act or the ability to engage in complex medical decision-making. Some add that surrogate decision-makers must display special care or concern toward the patient. This can be applied to an individual that is not a family member.

Surrogate Decision Maker Capacity And Competence

A surrogate decision-maker’s capacity and competence in making treatment decisions are measured legally and clinically. A study published in the Primary Care Companion of the Journal of Clinical Psychiatry defines capacity and competence. Competence is having enough ability and possessing legal qualifications while capacity is the assessment of an individual’s psychological abilities to form rational treatment decisions.

Powers And Limitations Of A Surrogate Decision Maker

The Texas Health and Human Services Commission mentions the powers a surrogate decision-maker  as follows. The first thing is that surrogate decision-makers are authorized to decide on major medical treatments. The second is they are also authorized to make decisions on major dental treatments. The third is that they are given the authority to release medical records and other information that are related to the treatment or condition that is needed to facilitate the process of obtaining consent for treatment. Lastly, they are authorized to consent decisions that the interdisciplinary team (IDT) agrees involve risk to individual protection and rights.

For the limitations, the surrogate decision-maker is not authorized to administer psychoactive medication. Psychoactive medication involves the usage of drugs that can affect mental processes like perception, consciousness, cognition, mood, and emotions, according to the World Health Organization (WHO). Another limitation is the use of a highly restrictive behavior procedure.

How To Become A Surrogate Decision-Maker For Your Family Member

There are several conditions to be met in order to become a surrogate decision-maker for your family member. The first condition is that you need to be identified and designated as actively involved family members. Actively involved family members are arranged based on the highest priority, which starts with the spouse, adult child, parent or stepparent, sibling, and other adult relatives such as a grandparent, aunt, uncle, niece, nephew, or cousin.

The next condition is that you need to know your family member’s preferences, personal values, and beliefs. Preferences, personal values, and beliefs are reflected in their advance directives or living wills. In case there is more than one family member who wants to be a surrogate decision-maker like you, you need to decide which one should be because only one surrogate decision-maker is allowed at a time. Other relatives of yours must sign a waiver and consent form. The waiver and consent form states that they agree with the person who was chosen as the surrogate decision-maker.

Default Surrogate Decision-Maker

Default surrogate decision-maker are people who are provided by a state in accordance with its state laws. This happens when the patient does not have a durable power of attorney for health care document or no court-appointed guardian with authority to make health care decisions.

For adult patients, the default surrogate decision-maker is normally a family member or a relative that is specified in a hierarchy by state laws, which starts with a spouse, an adult child, a sibling, a parent or guardian, and a relative. Many states are also considering a close friend as a default surrogate. Default surrogates can also be court-appointed guardians for patients with no family or close friends and who are alone in the hospital. For children, their parents or guardians are their default surrogate decision-makers.

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