If a patient with impaired decision-making capacity has a surrogate who decides they should undergo dialysis, despite the patient's refusal, is the patient required to undergo the treatment?

Decision-Making Authority When Patient Lacks Capacity

No, the patient does not have to undergo dialysis simply because the surrogate requests it—the surrogate's role is to represent what the patient would have wanted, not to impose their own preferences, and if the patient previously expressed refusal while still having some capacity to communicate preferences, that expression should guide the decision. 1, 2

Understanding the Surrogate's Proper Role

The fundamental principle here is that surrogates do not have an independent moral right to decide for someone else—they have an epistemological advantage (they know the patient best) that justifies their decision-making authority. 3 When a patient lacks full decision-making capacity requiring a surrogate, the surrogate's obligation is to make decisions based on:

• The patient's previously expressed values, goals, and preferences (substituted judgment standard) 1, 2
• The patient's best interests when prior wishes are unknown, considering medical factors, previously expressed values and beliefs, general well-being, and spiritual/religious welfare 2, 4

Critical distinction: The surrogate cannot simply impose their own values or what they personally want for the patient—this is called "projection bias" and represents a failure of the surrogate's duty. 1

When the Patient Has Expressed a Preference

If this patient verbally refused dialysis (even while lacking full decision-making capacity for complex medical decisions), this expression carries significant moral weight:

• The patient's own refusal, even if not fully "competent" in the legal sense, should be heavily weighted in determining what treatment aligns with their values 1, 5
• The surrogate's role is to advocate for what the patient would want, not override the patient's expressed wishes with their own judgment 1, 3
• If the patient is competent enough to refuse, the family cannot insist on dialysis—the decision belongs to the person 5

Resolving This Conflict

Step 1: Assess the patient's current capacity for this specific decision

• Decision-making capacity is decision-specific and can fluctuate 1
• Assess four elements: ability to understand relevant information, retain it, use/evaluate it, and communicate a decision 4
• If the patient has capacity for this decision, their refusal stands regardless of surrogate's wishes 5

Step 2: Determine what the patient would have wanted

• Engage in shared decision-making that prioritizes the patient's values, not the surrogate's preferences 1
• Explore with the surrogate: What did the patient say about dialysis? What are the patient's values about quality of life versus life prolongation? 1
• Document these discussions thoroughly 1

Step 3: Address surrogate's projection bias directly

• If the surrogate is making decisions based on their own values rather than the patient's, this violates their fiduciary duty 1
• The medical team should explicitly ask: "What would [patient's name] want in this situation?" rather than "What do you want us to do?" 1

Step 4: Consider whether dialysis is medically appropriate

• Treatment decisions must be both medically appropriate AND consistent with patient's values 1
• If dialysis offers no meaningful benefit or the burdens outweigh benefits, the physician has no obligation to provide it even if the surrogate requests it 5
• The law does not obligate nephrologists to provide treatment they believe is of no benefit or where burdens outweigh benefits 5

When Conflict Persists

If the surrogate continues to insist on dialysis contrary to the patient's expressed wishes:

• Enlist ethics consultation or institutional decision-making committees rather than allowing ad hoc decisions 1, 6
• Consider whether this surrogate should continue in that role if they cannot fulfill their duty to represent the patient's wishes 3
• Seek court clarification if necessary, particularly for major life-sustaining treatment decisions 6, 5
• A second medical opinion may help, but ultimately the Supreme Court of the jurisdiction may need to clarify if impasse persists 5

Critical Pitfalls to Avoid

• Do not assume the surrogate's authority is absolute—their role is to represent the patient, not exercise independent authority 3
• Do not proceed with dialysis simply to avoid conflict if it contradicts the patient's expressed wishes 1, 5
• Do not allow the loudest or most demanding party to become the de facto decision-maker without proper ethical assessment 6
• Do not ignore the patient's own verbal refusal simply because they lack full capacity for complex decisions 5

The Bottom Line

The surrogate's request for dialysis does not automatically override the patient's refusal. The medical team should facilitate a decision-making process that centers on what the patient would want, not what the surrogate wants. 1 If the patient expressed refusal and the surrogate is insisting on treatment contrary to those wishes, the surrogate is not fulfilling their proper role, and the medical team should not proceed with dialysis without further ethical and potentially legal clarification. 3, 5