Making Medical Decisions for Patients without Surrogates

Pope, Thaddeus Mason

doi:10.1056/nejmp1308197

Cited by 58 publications

(58 citation statements)

References 4 publications

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“…There has been an ongoing normative and policy discussion about who should decide for unrepresented patients, particularly regarding whether to continue or to limit life-sustaining treatment (Rubin and Courtwright 2015; White et al 2012; Pope 2013). Several recent articles have suggested that ethics committees are better situated to play this role than attending physicians, a common default.…”

Section: Discussionmentioning

confidence: 99%

“…This would be consistent with the broader literature on differences between patients, surrogates, and clinicians on predicting outcomes following critical illness, willingness to pursue treatments that have a low probability of success, and preferences for avoiding certain health states, such as long-term ventilator dependence (Cox et al 2009; Gramelspacher et al 1996; Schneiderman et al 1997). Ethics consultants’ involvement in the final decision with the attending physician, however, did not change the frequency with which the final decision was to limit LST, which may impact their imagined role as an independent third party (Pope 2013). …”

Section: Discussionmentioning

confidence: 99%

“…The most common expectation is that the treating medical team initiate legal proceedings for a court-appointed guardian if they can identify no other potential surrogate (Pope and Sellers 2011). The guardianship process, however, can move slowly, and public guardians are often overworked or simply unavailable (Pope 2013). …”

Section: Introductionmentioning

confidence: 99%

“…In a related multicentre study, however, only 19 per cent of decisions about LST were made with institutional or judicial review (White et al 2007). Despite this common default, recent commentators have argued that it is inappropriate for physicians to serve as surrogate decision-makers for the unrepresented (White, Jonsen, and Lo 2012; Pope 2013). Acknowledging the inefficiency of having courts formally designate guardians in every case, these authors have argued that multidisciplinary ethics committees—ideally unaffiliated with the treating institution—serve as surrogate decision-makers for the unrepresented (White, Jonsen, and Lo 2012; Pope 2013).…”

Section: Introductionmentioning

confidence: 99%

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The Role of a Hospital Ethics Consultation Service in Decision-Making for Unrepresented Patients

2017

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Despite increased calls for hospital ethics committees to serve as default decision-makers about life-sustaining treatment (LST) for unrepresented patients who lack decision-making capacity or a surrogate decision-maker and whose wishes regarding medical care are not known, little is known about how committees currently function in these cases. This was a retrospective cohort study of all ethics committee consultations involving decision-making about LST for unrepresented patients at a large academic hospital from 2007 to 2013. There were 310 ethics committee consultations, twenty-five (8.1 per cent) of which involved unrepresented patients. In thirteen (52.0 per cent) cases, the ethics consultants evaluated a possible substitute decision-maker identified by social workers and/or case managers. In the remaining cases, the ethics consultants worked with the medical team to contact previous healthcare professionals to provide substituted judgement, found prior advance care planning documents, or identified the patient’s best interest as the decision-making standard. In the majority of cases, the final decision was to limit or withdraw LST (72 per cent) or to change code status to Do Not Resuscitate/Do Not Intubate (12 per cent). Substitute decision-makers who had been evaluated through the ethics consultation process and who made the final decision alone were more likely to continue LST than cases in which physicians made the final decision (50 per cent vs 6.3 per cent, p = 0.04). In our centre, the primary role of ethics consultants in decision-making for unrepresented patients is to identify appropriate decision-making standards. In the absence of other data suggesting that ethics committees, as currently constituted, are ready to serve as substitute decision-makers for unrepresented patients, caution is necessary before designating these committees as default decision-makers.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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The Role of a Hospital Ethics Consultation Service in Decision-Making for Unrepresented Patients

2017

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“…Obtaining a legal guardianship is rarely done as it is time-consuming, costly, and emotionally taxing on the potential surrogate (Beauchamp 2009;Buchanan 1990;Herr 1994;Pope 2013). This may leave some patients without a legally authorized decision maker, even though they have friends or family members willing to serve as a surrogate.…”

mentioning

confidence: 99%

Physician understanding and application of surrogate decision-making laws in clinical practice

Comer

Gaffney

Stone

et al. 2016

AJOB Empirical Bioethics

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How Should Clinicians Navigate Decision Making for Unrepresented Patients?

Dempsey

DeMartino

2019

AMA Journal of Ethics

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Caring for patients who lack decision-making capacity is common in health care and presents numerous practical and ethical challenges. Unrepresented patients are vulnerable in part because they do not have anyone to help articulate their values and preferences, and they cannot do so themselves. This commentary suggests a deliberative approach to responding to these patients' needs. Case Ms B is a 65-year-old homeless woman with 2 years of progressively worsening altered mental status, anxiety, depression, and paranoia. After several prolonged involuntary admissions at an inpatient psychiatric center, during which her altered mental status was refractory to multiple modalities of treatment, psychiatrists began to suspect an organic cause of her altered mental status and psychiatric symptoms. She was admitted to the hospital for further workup. During her hospitalization, she intermittently refuses tests and medications. She yells, "Get out!" to anyone who enters her room. All blood tests and imaging are negative. After consultation with neurology, it is determined that Ms B needs a lumbar puncture for further workup, which she consistently refuses. After a thorough assessment, the primary team determines that Ms B does not have capacity to refuse a lumbar puncture. No family members or friends have been identified during this hospitalization or during previous admissions at the inpatient psychiatric facility.

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Making Medical Decisions for Patients without Surrogates

Cited by 58 publications

References 4 publications

The Role of a Hospital Ethics Consultation Service in Decision-Making for Unrepresented Patients

The Role of a Hospital Ethics Consultation Service in Decision-Making for Unrepresented Patients

Physician understanding and application of surrogate decision-making laws in clinical practice

How Should Clinicians Navigate Decision Making for Unrepresented Patients?

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