569 Surrogate Decision Making: Who Has the Ultimate Say in Patient Care?

2021 ◽  
Vol 42 (Supplement_1) ◽  
pp. S134-S135
Author(s):  
Todd F Huzar ◽  
Monica L Gerrek ◽  
Daniel J Freet
Keyword(s):  
Decision Making ◽  
The Other ◽  
Medical Decision ◽  
Surrogate Decision Making ◽  
Next Of Kin ◽  
Fourth Degree ◽  
Her Family ◽  
The Family ◽  
History Of ◽  
Surrogate Decision

Abstract Introduction Burn patients may present with an inability to communicate. In these cases, we need to rely on surrogates such as the Medical Power of Attorney (MPoA) or next of kin. A MPoA gives the agent the authority to participate in medical decision and in accordance with their wishes. The agent may consent to, refuse, withdraw, or withhold treatment, including life-sustaining interventions. At times, they may feel unable to participate in decision making without assistance (i.e. family members). The process can become more complicated and decision making can become “muddied” due to others influencing decisions. In our state, the MPoA is the proxy if the patient is unable to participate in decision making; however, there are cases when the patient doesn’t have an MPoA and the next of kin is the surrogate. In these cases, the next of kin would be consulted in the following order: spouse, adult children, parents, and nearest relatives. Some next of kin may not know the patient’s wishes complicating their care. Methods Two cases involving surrogates: #1: 60-year-old man with a history of HIV involved in a MVC and sustained 30% TBSA third and fourth degree burns to the face, torso, and extremities. The severity of his injuries and outcomes were discussed with his wife. She was not certain what her would want and she consulted her family because she did not know what to do; however, she knew that he would not want to live like this. After talking to the family, the kids “over-ruled” her. They wanted aggressive care despite the risks of complications and inability to perform ADLs because of his severe facial and hand burns. Case#2: 40 something year-old man with a history of schizophrenia that sustained 65% TBSA third and fourth degree burns to his face, neck, torso, and extremities due to self-immolation. The patient’s mother was identified, and it was explained to the patient’s mother that if he did survive his injury, he will not be able to perform any of his ADLs due his hand and facial burns. The patient’s mother wanted everything done for her son. Results Both patients were unable to perform ADLs due to their injuries. One patient was discharged for further inpatient care and the other was discharged home because his mother refused further care. The first patient was unable to communicate about his thoughts on his outcome. The other patient was discharged home. He was upset about what he looked like. He also told the staff that he will do his best to finish what he started. Conclusions Complex issues can arise when the patient cannot communicate their wishes and the next of kin plays the role of surrogate. The family may disagree and alter the decision-making process. After seeing this scenario play out and patients not being happy about their outcomes, the policies regarding surrogate decision making should be re-evaluated.

All things considered: Surrogate decision-making on behalf of patients in the minimally conscious state

2020 ◽  
Vol 15 (3) ◽  
pp. 111-119
Author(s):  
L Syd M Johnson ◽  
Kathy L Cerminara
Keyword(s):  
Decision Making ◽  
Medical Decision Making ◽  
Vegetative State ◽  
Minimally Conscious State ◽  
Conscious State ◽  
Disorders Of Consciousness ◽  
Medical Decision ◽  
Surrogate Decision Making ◽  
Surrogate Decision ◽  
Minimally Conscious

The minimally conscious state presents unique ethical, legal, and decision-making challenges because of the combination of diminished awareness, phenomenal experience, and diminished or absent communication. As medical expertise develops and technology advances, it is likely that more and more patients with disorders of consciousness will be recognized as being in the minimally conscious state, with minimal to no ability to participate in medical decision-making. Here we provide guidance useful for surrogates and medical professionals at any medical decision point, not merely for end-of-life decision-making. We first consider the legal landscape: precedent abounds regarding unconscious patients in coma or the vegetative state/Unresponsive Wakefulness Syndrome (VS/UWS), but there is little legal precedent involving patients in the minimally conscious state. Next we consider surrogates’ ethical authority to make medical decisions on behalf of patients with disorders of consciousness. In everyday medical decision-making, surrogates generally encounter few, if any, restrictions so long as they adhere to an idealized hierarchy of decision-making standards designed to honor patient autonomy as much as possible while ceding to the reality of what may or may not be known about a patient’s wishes. We conclude by proposing an ethically informed, practical guide for surrogate decision-making on behalf of patients in the minimally conscious state.

scholarly journals SURROGATES’ DECISION-MAKING CONFIDENCE AND COLLABORATIVE WILLINGNESS ON THE POST: THE ROLE OF SOCIAL NORMS

2019 ◽  
Vol 3 (Supplement_1) ◽  
pp. S138-S138
Author(s):  
Rachael Spalding ◽  
Jenna Wilson ◽  
Barry Edelstein
Keyword(s):  
Decision Making ◽  
Social Norms ◽  
Indirect Effect ◽  
Self Report ◽  
Medical Decision ◽  
Surrogate Decision Making ◽  
Consideration Of Future Consequences ◽  
Perceived Social Norms ◽  
Surrogate Decision ◽  
Future Consequences

Abstract When patients become incapacitated due to illness or frailty, “surrogates” work with patients’ providers to make medical decisions on their behalf. In surrogate decision-making situations, surrogates’ decision-making confidence predicts collaborative willingness, or the extent to which they are willing to work with the patient’s providers when making decisions (Spalding & Edelstein, under review). In an attempt to explain this finding, the current study examined whether perceived social norms for patient-physician collaboration and another psychological variable, consideration of future consequences, mediated the relation between decision-making confidence and collaborative willingness. Participants (n= 172) from Amazon’s Mechanical Turk completed self-report measures and a hypothetical surrogate decision-making task. A parallel multiple mediation analysis using 5000 bootstrapped samples with the PROCESS macro (Hayes, 2013) was conducted. The overall model explained 43.4% of the variance in collaborative willingness, F(4, 166) = 9.59, p< .001. There was a significant indirect effect of decision-making confidence on collaborative willingness through perceived social norms (b= .068, SE= .034, 95% CI [.014, .154]). There was not a significant indirect effect through consideration of future consequences. After including the significant indirect path through perceived social norms, the direct effect (b= .348, p< .001) of decision-making confidence on collaborative willingness was reduced (b= .243, p= .003). Thus, perceptions of social norms partially accounted for the relation between decision-making confidence and collaborative willingness. This finding illustrates how social perceptions of patient-provider collaboration can facilitate desirable medical decision-making behaviors, such as collaboration.

Surrogate Decision-making for Incompetent Elderly Patients: The Role of Informal Representatives

2012 ◽  
Vol 19 (1) ◽  
pp. 61-68 ◽  
Author(s):  
Sjef Gevers ◽  
Joseph Dute ◽  
Herman Nys
Keyword(s):  
Decision Making ◽  
Best Interests ◽  
Surrogate Decision Making ◽  
Next Of Kin ◽  
Incompetent Patient ◽  
The Law ◽  
European Standards ◽  
Surrogate Decision ◽  
Informal Approach

Abstract Informal or unofficial representation refers to the practice (more common in some European jurisdictions than in others), that persons not designed by a court or by the patient himself, make medical decisions on the patient’s behalf in case of their incompetence. If the law provides for this, it is usually next of kin (spouse, children, brothers and sisters, etc.) who are allowed to act in such a capacity. Informal representation raises several questions. Are family members always familiar with what their relative would have wished, ready to take responsibility, and not too much reigned by their emotions? The basic legal concern is whether there are sufficient procedural and other safeguards to protect the incompetent patient from representatives who do not serve their best interests. In addressing these issues, after a brief survey of the law in the Netherlands as compared with that in Belgium, Germany and England/Wales, we will argue that informal representation as such is not at variance with international and European standards. However, an ‘informal’ approach to surrogate decision-making should always go together with sufficient protection of the incompetent patient, including procedural safeguards with regard to the decision that the patient is incompetent, limits to the decision-making power of informal representatives and effective forms of conflict resolution.

What would people think? Perceived social norms, willingness to serve as a surrogate, and end-of-life treatment decisions

2020 ◽  
pp. 1-9
Author(s):  
Rachael Spalding ◽  
JoNell Strough ◽  
Barry Edelstein
Keyword(s):  
Decision Making ◽  
Mechanical Ventilation ◽  
End Of Life ◽  
Contextual Factors ◽  
Medical Decision ◽  
Decision Making Process ◽  
Surrogate Decision Making ◽  
Willingness To Serve ◽  
Surrogate Decision ◽  
End Of Life Treatment

Abstract Background Population aging has increased the prevalence of surrogate decision making in healthcare settings. However, little is known about factors contributing to the decision to become a surrogate and the surrogate medical decision-making process in general. We investigated how intrapersonal and social-contextual factors predicted two components of the surrogate decision-making process: individuals’ willingness to serve as a surrogate and their tendency to select various end-of-life treatments, including mechanical ventilation and palliative care options. Method An online sample (N = 172) of adults made hypothetical surrogate decisions about end-of-life treatments on behalf of an imagined person of their choice, such as a parent or spouse. Using self-report measures, we investigated key correlates of willingness to serve as surrogate (e.g., decision-making confidence, willingness to collaborate with healthcare providers) and choice of end-of-life treatments. Results Viewing service as a surrogate as a more typical practice in healthcare was associated with greater willingness to serve. Greater decision-making confidence, greater willingness to collaborate with patients’ physicians, and viewing intensive, life-sustaining end-of-life treatments (e.g., mechanical ventilation) as more widely accepted were associated with choosing more intensive end-of-life treatments. Significance of results The current study's consideration of both intrapersonal and social-contextual factors advances knowledge of two key aspects of surrogate decision making — the initial decision to serve as surrogate, and the surrogate's selection of various end-of-life treatment interventions. Providers can use information about the role of these factors to engage with surrogates in a manner that better facilitates their decision making. For instance, providers can be sensitive to potential cultural differences in surrogate decision-making tendencies or employing decision aids that bolster surrogates’ confidence in their decisions.

Extubating Mrs. K: Psychological Aspects of Surrogate Decision Making

1999 ◽  
Vol 27 (1) ◽  
pp. 81-86 ◽  
Author(s):  
Tia Powell
Keyword(s):  
Decision Making ◽  
Alcohol Intoxication ◽  
Medical Decision ◽  
Current Status ◽  
Deep Coma ◽  
Next Of Kin ◽  
Old Russian ◽  
Surrogate Decision ◽  
One Year ◽  
Probable Depression

Mrs. K is a thirty-one-year-old Russian-speaking mother of two, who was brought in by ambulance after attempting suicide by jumping in front of train. Probable depression x months. Stressor: lost custody battle over older child. Current status: deep coma, ventilator-dependent, and prognosis grim. Next of kin is estranged husband; he demands participation in medical decision making. Legal proxy is patient's boyfriend; forcibly removed from the intensive care unit (ICU) for agitated behavior and alcohol intoxication.I magine the difficulty for the ICU staff as it tries to patch together the broken body of Mrs. K, described above. If, as appears likely, the physicians’ efforts begin to fail, who will speak for this patient, who can no longer speak for herself, and determine the appropriate goals and limits of intensive medical care?

scholarly journals Determining medical decision-making capacity in brain tumor patients: why and how?

2020 ◽  
Vol 7 (6) ◽  
pp. 599-612 ◽  
Author(s):  
Andrea Pace ◽  
Johan A F Koekkoek ◽  
Martin J van den Bent ◽  
Helen J Bulbeck ◽  
Jane Fleming ◽  
...  
Keyword(s):  
Decision Making ◽  
Brain Tumor ◽  
Medical Decision Making ◽  
Clinical Decision Making ◽  
Best Interests ◽  
Medical Decision ◽  
Surrogate Decision Making ◽  
Tumor Patients ◽  
Decision Making Capacity ◽  
Surrogate Decision

Abstract Background Brain tumor patients are at high risk of impaired medical decision-making capacity (MDC), which can be ethically challenging because it limits their ability to give informed consent to medical treatments or participation in research. The European Association of Neuro-Oncology Palliative Care Multidisciplinary Task Force performed a systematic review to identify relevant evidence with respect to MDC that could be used to give recommendations on how to cope with reduced MDC in brain tumor patients. Methods A literature search in several electronic databases was conducted up to September 2019, including studies with brain tumor and other neurological patients. Information related to the following topics was extracted: tools to measure MDC, consent to treatment or research, predictive patient- and treatment-related factors, surrogate decision making, and interventions to improve MDC. Results A total of 138 articles were deemed eligible. Several structured capacity-assessment instruments are available to aid clinical decision making. These instruments revealed a high incidence of impaired MDC both in brain tumors and other neurological diseases for treatment- and research-related decisions. Incapacity appeared to be mostly determined by the level of cognitive impairment. Surrogate decision making should be considered in case a patient lacks capacity, ensuring that the patient’s “best interests” and wishes are guaranteed. Several methods are available that may help to enhance patients’ consent capacity. Conclusions Clinical recommendations on how to detect and manage reduced MDC in brain tumor patients were formulated, reflecting among others the timing of MDC assessments, methods to enhance patients’ consent capacity, and alternative procedures, including surrogate consent.

scholarly journals Developing the family support tool: An interactive, web-based tool to help families navigate the complexities of surrogate decision making in ICUs

2020 ◽  
Vol 56 ◽  
pp. 132-139 ◽  
Author(s):  
Angela O. Suen ◽  
Rachel A. Butler ◽  
Robert Arnold ◽  
Brad Myers ◽  
Holly O. Witteman ◽  
...  
Keyword(s):  
Decision Making ◽  
Family Support ◽  
Surrogate Decision Making ◽  
Web Based ◽  
Support Tool ◽  
The Family ◽  
Surrogate Decision

scholarly journals What Would People Think? Social Norms, Willingness to Serve as a Surrogate, and End-of-Life Treatment Decisions

2020 ◽  
Vol 4 (Supplement_1) ◽  
pp. 421-421
Author(s):  
Rachael Spalding ◽  
JoNell Strough ◽  
Barry Edelstein
Keyword(s):  
Decision Making ◽  
Mechanical Ventilation ◽  
End Of Life ◽  
Contextual Factors ◽  
Medical Decision ◽  
Decision Making Process ◽  
Surrogate Decision Making ◽  
Willingness To Serve ◽  
Surrogate Decision ◽  
End Of Life Treatment

Abstract Population aging has increased the prevalence of surrogate decision making in healthcare settings. However, little is known about factors contributing to the decision to become a surrogate and the surrogate medical decision-making process in general. We investigated how intrapersonal and social-contextual factors predicted two components of the surrogate decision-making process: individuals’ willingness to serve as a surrogate and their tendency to select various end-of-life treatments, including mechanical ventilation and palliative care options. An online sample (N=172) of adults made hypothetical surrogate decisions about end-of-life treatments on behalf of an imagined individual of their choice, such as a parent or spouse. Using self-report measures, we investigated key correlates of willingness to serve as surrogate (e.g., decision-making confidence, willingness to collaborate with healthcare providers), and choice of end-of-life treatments. Viewing service as a surrogate as a more typical practice in healthcare was associated with greater willingness to serve. Greater decision-making confidence, greater willingness to collaborate with patients’ physicians, and viewing intensive, life-sustaining end-of-life treatments (e.g., mechanical ventilation) as more widely accepted were associated with choosing more intensive end-of-life treatments. The current study’s consideration of both intrapersonal and social-contextual factors advances knowledge of two key aspects of surrogate decision making—the initial decision to serve as surrogate, and the surrogate’s selection of various end-of-life treatment interventions. Providers can use information about the role of these factors to engage with surrogates in a manner that better facilitates their decision making.

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