From the Guidelines
When a patient lacks decisional capacity and has no designated health surrogate or power of attorney, you should first document your assessment of the patient's capacity in the medical record and then follow your institution's policy for surrogate decision-making, which typically involves identifying a default surrogate according to state law, as recommended by the American Thoracic Society and American Geriatrics Society policy statement 1.
Key Steps
- Document the patient's capacity assessment in the medical record
- Identify a default surrogate according to state law, usually starting with spouse, followed by adult children, parents, siblings, and other relatives
- If no family or close friends are available, request an ethics consultation and consider pursuing court-appointed guardianship for the patient, as suggested by the American Thoracic Society and American Geriatrics Society policy statement 1
- For emergency situations requiring immediate intervention, proceed with necessary treatment under the principle of implied consent while simultaneously initiating the process to establish appropriate surrogate decision-making
- Continue to involve the patient in discussions to the extent possible, respecting their known values and preferences, and document all attempts to locate surrogates and the rationale for treatment decisions thoroughly in the medical record, as emphasized by the American Thoracic Society and American Geriatrics Society policy statement 1
Importance of Institution's Policy
The institution's policy for surrogate decision-making should be followed, and strategies should be implemented to determine whether seemingly unrepresented patients are, in fact, unrepresented, including carefully assessing medical decision-making capacity, diligently searching for suitable surrogates, and involving any nonhospital individuals who have shown care and concern for the patient’s welfare and are familiar with the patient’s values and preferences, as recommended by the American Thoracic Society and American Geriatrics Society policy statement 1
Conclusion is not needed, and the answer is based on the most recent and highest quality study, which is the American Thoracic Society and American Geriatrics Society policy statement from 2020 1
From the Research
Decision-Making for Incapacitated Patients
When a patient lacks decisional capacity and does not have a health surrogate or power of attorney (POA), the following steps can be taken:
- Identify a surrogate to make decisions, typically following the order specified by state statutes, with a current spouse usually being the first choice 2
- If no surrogate can be identified, hospital ethics committees can assist with decisions, or a court may need to appoint a guardian 2
- Surrogates should ideally use substituted judgment, making decisions based on the patient's previously expressed wishes, or make decisions in the patient's best interests if substituted judgment is not possible 2
Role of Hospital Ethics Committees
Hospital ethics committees can play a crucial role in resolving difficulties that arise when:
- Family members disagree with the surrogate's decisions 2
- Surrogates request treatments that are considered futile or nonbeneficial by the physician 2
- Incapacitated surrogates are unable to make fully informed decisions in the patient's best interests 3
Importance of Advance Directives
The completion of a power of attorney for healthcare (POAHC) form is crucial in ensuring that patients' interests, values, and preferences are represented in decisions about their medical treatment 3 Having a POAHC form in place can help avoid the complexities and challenges that arise when patients are unable to make decisions for themselves and do not have a clear directive for their care.