Surrogate decision making for unrepresented patients: Proposing a harm reduction interpretation of the best interest standard

2020 ◽  
Vol 15 (2) ◽  
pp. 57-64
Author(s):  
Phoebe Friesen ◽  
Nada Gligorov
Keyword(s):  
Decision Making ◽  
Harm Reduction ◽  
Well Being ◽  
The United States ◽  
Alternative Interpretation ◽  
Surrogate Decision Making ◽  
Best Interest ◽  
Medical Decisions ◽  
Best Interest Standard ◽  
Surrogate Decision

Unrepresented patients are individuals who lack decision makingcapacity and have no family or friends to make medical decisions for them. This population is growing in number in the United States, particularly within emergency and intensive care settings. While some bioethical discussion has taken place in response to the question of who ought to make decisions for these patients, the issue of how surrogate medical decisions ought to be made for this population remains unexplored. In this paper, we argue that standard applications of surrogate decision making principles in health care are not well suited to many unrepresented patients with long-term mental health diagnosis. We argue that when applied to this population, the substituted judgment standard, designed to preserve patient preferences and values, may lead to the exclusion of their preferences. We argue further that the application of the best interest standard runs the risk of leading to harmful cases of overtreatment or undertreatment. We offer an alternative interpretation of the best interest principle that is better able to promote the well-being of unrepresented patients, especially for those who lack capacity because of mental disorders. This alternative is based on the practices and principles of harm reduction and includes three components: emphasis on considering the expressed preferences of unrepresented patients, a focus on reducing harm as well as the delivery of clinical benefits, and a recognition of the importance of promoting trust.

Whose Decision Is This?

2020 ◽  
pp. 3-6
Author(s):  
Elissa G. Miller
Keyword(s):  
Decision Making ◽  
End Of Life ◽  
End Of Life Care ◽  
Surrogate Decision Making ◽  
Life Care ◽  
Best Interest ◽  
Best Interest Standard ◽  
Surrogate Decision Makers ◽  
Surrogate Decision ◽  
End Of Life Decision

Decision-making in palliative and end-of-life care can be difficult to navigate. This is even more so in pediatric palliative and end of life care when parents may disagree with each other or for teenagers who are not yet legally able to make their own medical decisions. Surrogate decision making can also complicate end of life decision making in pediatrics. To navigate these complex situations, the best interest standard, harm principle, and other standards are often applied when concerns arise over surrogate decision-making. This chapter presents a discussion of the ethical principles and a recommended approach to managing clinical situations with uncertain or conflicting surrogate decision-makers.

Ethics in Pediatric Anesthesiology

2018 ◽  
Author(s):  
Monica Shah ◽  
David Waisel
Keyword(s):  
Decision Making ◽  
Informed Consent ◽  
Ethics Committees ◽  
Decision Makers ◽  
Best Interest ◽  
Medical Decisions ◽  
Risks And Benefits ◽  
Surrogate Decision Makers ◽  
Surrogate Decision ◽  
Life Therapy

Ethical principles affect daily decision-making in pediatric anesthesiology. These medical decisions are interlaced with the ethical components of informed consent and obligations to the child and family. Informed consent in pediatrics includes the concepts of best interest, in which the parents or other surrogate decision-makers choose acceptable treatment for the child, and assent, which enables children to participate in decision-making to the best of their ability. Of equal significance to informed consent, the process of informed refusal requires anesthesiologists to more fully inform children and their guardians about risks and benefits while respecting refusal of assent and avoiding coercion. Pediatric considerations regarding end-of-life therapy are slightly different than adult considerations. To help resolve these ethical dilemmas, ethics committees are available for consultations to assist the medical team, family members, and patients in order to make the best decision for the child.

In the patient’s best interest: appraising social network site information for surrogate decision making

2018 ◽  
Vol 44 (12) ◽  
pp. 851-856 ◽  
Author(s):  
Shahla Siddiqui ◽  
Voo Teck Chuan
Keyword(s):  
Decision Making ◽  
Social Network ◽  
Mental Capacity ◽  
Surrogate Decision Making ◽  
Best Interest ◽  
Social Network Site ◽  
Code Of Practice ◽  
Network Site ◽  
Surrogate Decision ◽  
Mental Capacity Act

This paper will discuss why and how social network sites ought to be used in surrogate decision making (SDM), with focus on a context like Singapore in which substituted judgment is incorporated as part of best interest assessment for SDM, as guided by the Code of Practice for making decisions for those lacking mental capacity under the Mental Capacity Act (2008). Specifically, the paper will argue that the Code of Practice already supports an ethical obligation, as part of a patient-centred care approach, to look for and appraise social network site (SNS) as a source of information for best interest decision making. As an important preliminary, the paper will draw on Berg’s arguments to support the use of SNS information as a resource for SDM. It will also supplement her account for how SNS information ought to be weighed against or considered alongside other evidence of patient preference or wishes, such as advance directives and anecdotal accounts by relatives.

The Medical Surrogate as Fiduciary Agent

2017 ◽  
Vol 45 (3) ◽  
pp. 402-420
Author(s):  
Dana Howard
Keyword(s):  
Decision Making ◽  
Advance Care Planning ◽  
Care Planning ◽  
Surrogate Decision Making ◽  
Best Interest ◽  
New Approach ◽  
Novel Approach ◽  
Advance Care ◽  
Surrogate Decision

Within bioethics, two prevailing approaches structure how we think about the role of medical surrogates and the decisions that they must make on behalf of incompetent patients. One approach views the surrogate primarily as the patient's agent, obediently enacting the patient's predetermined will. The second approach views the surrogate as the patient's custodian, judging for herself how to best safeguard the patient's interests. This paper argues that both of these approaches idealize away some of the ethically relevant features of advance care planning that make patient preferences so inscrutable and surrogate decision-making so burdensome. It proposes a new approach to surrogate decision-making, the Fiduciary Agency Approach. On this novel approach, the surrogate has authority to not only act on the patient's behalf as the patient's agent but also to decide on the patient's behalf as the patient's fiduciary. One upshot of this new approach is that surrogates must sometimes go against the expressed dictates of the patients' advance directives not necessarily because doing so would be in the patient's best interest but rather because doing so would best represent the patients' will.

Best Interest of the Child: Surrogate Decision Making and the Economics of Externalities

2011 ◽  
Vol 8 (3) ◽  
pp. 289-298 ◽  
Author(s):  
Joseph P. DeMarco ◽  
Douglas P. Powell ◽  
Douglas O. Stewart
Keyword(s):  
Decision Making ◽  
Surrogate Decision Making ◽  
Best Interest ◽  
Surrogate Decision

Avoiding Family Feuds: Responding to Surrogate Demands for Life-Sustaining Interventions

1999 ◽  
Vol 27 (1) ◽  
pp. 74-80 ◽  
Author(s):  
Ann Alpers ◽  
Bernard Lo
Keyword(s):  
Decision Making ◽  
Advance Directives ◽  
Family Members ◽  
Active Role ◽  
Best Interest ◽  
Ethical Guidelines ◽  
Medical Decisions ◽  
Case Examples ◽  
Surrogate Decision ◽  
Personal Community

The laws and ethical guidelines governing decision making for incompetent patients evolved from controversies in which family members refused life-sustaining interventions. These cases led to a consensus that advance directives to limit interventions should be respected and that a surrogate designated by the patient or specified by statute could refuse interventions, even when other relatives disagreed. Surrogate decision-making statutes and ethical principles about respect for delegated autonomy promote an active role for family members or other surrogates in medical decisions for incompetent patients. Inviting surrogates to participate actively in medical decisions recognizes the importance of the patient's personal community and assures that decisions will reflect the patient's own preferences and values.The standard approach to decisions for incompetent adults gives advance directives priority over a surrogate's substituted judgment, which in turn has priority over assessments of the patient's best interest. A patient may express advance directives by appointing a proxy, stating specific preferences, or articulating general values. We use case examples to illustrate the limitations of all three types of advance directives.

scholarly journals Surviving Surrogate Decision-Making: What Helps and Hampers the Experience of Making Medical Decisions for Others

2007 ◽  
Vol 22 (9) ◽  
pp. 1274-1279 ◽  
Author(s):  
Elizabeth K. Vig ◽  
Helene Starks ◽  
Janelle S. Taylor ◽  
Elizabeth K. Hopley ◽  
Kelly Fryer-Edwards
Keyword(s):  
Decision Making ◽  
Surrogate Decision Making ◽  
Medical Decisions ◽  
Surrogate Decision ◽  
Decisions For Others

Indiana Medical Resident’s Knowledge of Surrogate Decision Making Laws

2021 ◽  
pp. 0272684X2110047
Author(s):  
Stephanie Bartlett ◽  
Lyle P. Fettig ◽  
Peter H. Baenziger ◽  
Eliana N. DiOrio ◽  
Kayla M. Herget ◽  
...  
Keyword(s):  
Decision Making ◽  
Clinical Practice ◽  
Treatment Options ◽  
Family Members ◽  
Veterans Affairs ◽  
Medical Residents ◽  
Surrogate Decision Making ◽  
Medical Decisions ◽  
Surrogate Decision ◽  
Va Hospitals

Introduction During the care of incapacitated patients, physicians, and medical residents discuss treatment options and gain consent to treat through healthcare surrogates. The purpose of this study is to ascertain medical residents’ knowledge of healthcare consent laws, application during clinical practice, and appraise the education residents received regarding surrogate decision making laws. Methods Beginning in February of 2018, 35 of 113 medical residents working with patients within Indiana completed a survey. The survey explored medical residents’ knowledge of health care surrogate consent laws utilized in Indiana hospitals and Veterans Affairs (VA) hospitals via clinical vignettes. Results Only 22.9% of medical residents knew the default state law in Indiana did not have a hierarchy for settling disputes among surrogates. Medical residents correctly identified which family members could participate in medical decisions 86% of the time. Under the Veterans Affairs surrogate law, medical residents correctly identified appropriate family members or friends 50% of the time and incorrectly acknowledged the chief decision makers during a dispute 30% of the time. All medical residents report only having little or some knowledge of surrogate decision making laws with only 43% having remembered receiving surrogate decision making training during their residency. Conclusions These findings demonstrate that medical residents lack understanding of surrogate decision making laws. In order to ensure medical decisions are made by the appropriate surrogates and patient autonomy is upheld, an educational intervention is required to train medical residents about surrogate decision making laws and how they are used in clinical practice.

Considering a family systems approach to surrogate decision-making.

2017 ◽  
Vol 35 (1) ◽  
pp. 85-87
Author(s):  
Elizabeth K. Vig ◽  
Janelle S. Taylor ◽  
Ann M. O'Hare
Keyword(s):  
Decision Making ◽  
Family Systems ◽  
Systems Approach ◽  
Surrogate Decision Making ◽  
Surrogate Decision
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