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?

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 The judgment grounds in surrogate decision-making in Japanese clinical practice: A qualitative survey

2020 ◽  
Author(s):  
Masashi Tanaka ◽  
Kayoko Ohnishi ◽  
Aya Enzo ◽  
Taketoshi Okita ◽  
Atsushi Asai
Keyword(s):  
Decision Making ◽  
Clinical Practice ◽  
Best Interests ◽  
Current Status ◽  
Surrogate Decision Making ◽  
Inclusion Criteria ◽  
Surrogate Decision ◽  
Factor Type ◽  
Family Preference ◽  
Made In

Abstract Background Surrogate decision-making is expected to become more prevalent in Japanese clinical practice. In recent years, activities to promote advanced care planning (ACP) have gathered momentum, which may potentially affect the ways in which judgments are made in surrogate decision-making. The purpose of this study is to clarify the current judgment grounds on which surrogate decisions are made in Japan. Methods We adopted a qualitative research method that was based on semi-structured interviews to reveal the judgment grounds in surrogate decision-making involving critical, life-sustaining treatment choices in acute hospitals.  Results We received a list of 228 participants who met the inclusion criteria. Of these, we interviewed 15 participants. We analyzed the content of the 14 transcribed texts, eliminating one text that did not meet the inclusion criteria. We extracted a total of four core categories, 17 categories, 35 subcategories, and 55 codes for qualitative analysis of interviews regarding the judgement grounds in surrogate decision-making. The four core categories are as follows: Type 1 "Patient preference-oriented factor," Type 2 "Patient interest-oriented factor," Type 3 "Family preference-oriented factor," and Type 4 "Balanced patient/family preference-oriented factor." Type 4 was the reasoning related to an attempt to balance preferences of the patient and those of the surrogate decision-maker.  Conclusions This study revealed the current status of surrogate decision-making about important matters related to a patient’s life in Japan. Surrogate decision-makers base their decisions not only on the preferences and best interests of the patient, but on their own preferences as well. In the future, we believe that surrogate decisions-makers will be required to consider the judgment grounds from a more diverse perspective and that such attitudes should be ethically accepted. 

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.

scholarly journals The judgment grounds in surrogate decision-making in Japanese clinical practice: A qualitative survey

2020 ◽  
Author(s):  
Masashi Tanaka ◽  
Kayoko Ohnishi ◽  
Aya Enzo ◽  
Taketoshi Okita ◽  
Atsushi Asai
Keyword(s):  
Decision Making ◽  
Clinical Practice ◽  
Decision Makers ◽  
Best Interests ◽  
Current Status ◽  
Surrogate Decision Making ◽  
Surrogate Decision Makers ◽  
Surrogate Decision ◽  
Family Preference ◽  
Made In

Abstract Background Surrogate decision-making is expected to become more prevalent in Japanese clinical practice. In recent years, activities to promote advanced care planning (ACP) have gathered momentum ,which may potentially affect the ways in which judgments are made in surrogate decision-making. The purpose of this study is to clarify the current judgment grounds on which surrogate decisions are made in Japan. Methods We adopted a qualitative research method that was based on semi-structured interviews to reveal the judgement grounds in surrogate decision-making involving critical, life-related choices in acute hospitals. Results We interviewed 15 participants. We analyzed the content of the 14 transcribed texts, eliminating one text that does not meet the inclusion criteria. We extracted a total of 4 core categories, 17 categories, 35 subcategories, and 55 codes as an analysis results of interviews regarding the judgment grounds in surrogate decision-making. The four categories are as follows: type 1“Patient preference-oriented factor”, type2“Patient interest-oriented factor”, type3“Family preference-oriented factor”,and type4 “Balanced patient/family preference-oriented factor”. Conclusions This study revealed the current status of surrogate decision-making in Japan: when making decisions about important matters related to a patient’s life, surrogate decision-makers base their decisions not only on the preferences and best interests of the patient, but on their own preferences as well. Included in the preferences of surrogate decision-makers were their own views of life and death, their values, and care burden. Given the cultural and social backgrounds in Japan, it remains unclear whether ACP can be properly reflected in judgment grounds in surrogate decision-making. It would be undesirable to base judgments solely on the principle of respect for autonomy or the principles of surrogate decision-making. In the future, we believe that surrogate decisions-makers will be required to consider the judgment grounds from a more diverse perspective and that such attitudes should be ethically accepted.

Substituted Judgment in Medical Practice: Evidentiary Standards on a Sliding Scale

1997 ◽  
Vol 25 (1) ◽  
pp. 22-29 ◽  
Author(s):  
Mark R. Tonelli
Keyword(s):  
Decision Making ◽  
Daily Practice ◽  
Medical Decision ◽  
Sufficient Evidence ◽  
State Court ◽  
Substituted Judgment ◽  
Sliding Scale ◽  
Surrogate Decision ◽  
Evidentiary Standards ◽  
Substituted Judgment Standard

Consensus is growing among ethicists and lawyers that medical decision making for incompetent patients who were previously competent should be made in accordance with that person's prior wishes and desires. Moreover, this legal and ethical preference for the substituted judgment standard has found its way into the daily practice of medicine. However, what appears on the surface to be an agreement between jurists, bioethicists, and clinicians obscures the very real differences between disciplines regarding the actual implementation of the sub stituted judgment standard. Ethicists and judges have carefully outlined how substituted judgments ought to be made and evaluated. Although differences arise, especially at the state court level, regarding the scope of the substituted judgment standard and its relation to other standards of surrogate decision making, agreement is fairly widespread on the priority of substituted judgment and on the necessity of sufficient evidence being available in order to support a particular substituted judgment.

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