Who is the most appropriate surrogate decision maker for a critically ill patient with acute hypoxic respiratory failure from influenza A, requiring ongoing mechanical ventilation, who has failed multiple attempts at spontaneous breathing trials and is unable to make informed decisions regarding her care, including consideration of a tracheostomy?

Surrogate Decision Maker Selection for Tracheostomy Consent

The most appropriate surrogate decision maker is the patient's spouse or domestic partner, followed by adult children, then parents, and finally siblings—in that hierarchical order—unless the patient has previously designated a healthcare proxy through an advance directive.

Legal Hierarchy of Surrogate Decision Makers

When a critically ill patient lacks decision-making capacity, most jurisdictions follow a standardized legal hierarchy for surrogate selection:

• First priority: Healthcare proxy or durable power of attorney for healthcare if previously designated by the patient in an advance directive
• Second priority: Spouse or domestic partner as they typically have the most intimate knowledge of the patient's values and preferences
• Third priority: Adult children (if multiple children, they should reach consensus)
• Fourth priority: Parents of the patient
• Fifth priority: Adult siblings
• Sixth priority: Other relatives or close friends who have maintained regular contact

This hierarchy reflects both legal standards and the presumption that those closest to the patient are most likely to understand their values, goals, and treatment preferences 1.

Shared Decision-Making Framework in Critical Care

The American College of Critical Care Medicine and American Thoracic Society define shared decision-making as "a collaborative process that allows patients, or their surrogates, and clinicians to make health care decisions together, taking into account the best scientific evidence available, as well as the patient's values, goals, and preferences" 1.

For major treatment decisions like tracheostomy, clinicians should engage surrogates in a shared decision-making process that includes three main elements 1:

1. Information exchange: Clinicians share treatment options, risks, and benefits (including palliative care options), while surrogates share the patient's values and preferences
2. Deliberation: Both parties discuss which option aligns best with the patient's goals
3. Decision-making: Agreement on the treatment plan to implement

Key Communication Principles with Surrogates

When discussing tracheostomy with the surrogate, the ICU team should 1:

• Establish trust and provide emotional support throughout the conversation
• Assess the surrogate's understanding of the patient's current condition and prognosis
• Explain that there are options to choose from, not just a single recommended path
• Clarify principles of surrogate decision-making: The surrogate's role is to represent what the patient would want, not what the surrogate personally prefers
• Elicit the patient's known values and preferences from the surrogate
• Tailor the decision-making process to the surrogate's preferred level of involvement, as preferences vary significantly—while most surrogates prefer shared responsibility, some prefer more or less control 1

Important Considerations for This Clinical Scenario

Surrogates often have more optimistic expectations than physicians regarding patient outcomes 2. Research shows surrogates expect higher rates of survival (91% vs 65%) and good quality of life (71% vs 40%) compared to physicians 2. This optimism is particularly pronounced among surrogates who are most confident in their assessments 2.

The decision-making approach differs between surrogates and physicians 2:

• Confident surrogates' treatment decisions are less influenced by prognostic expectations
• Physicians' decisions are more strongly tied to their prognostic assessments when they are confident

This divergence underscores the importance of clear prognostic communication and exploration of the patient's values when discussing tracheostomy with surrogates.

Common Pitfalls to Avoid

• Do not assume the most vocal family member is the appropriate surrogate—follow the legal hierarchy unless the patient designated otherwise
• Do not proceed with implied consent for major procedures like tracheostomy without proper surrogate authorization
• Do not frame the discussion as seeking permission—instead, present it as collaborative decision-making about what aligns with the patient's values 1
• Do not delay the conversation waiting for the patient to regain capacity if she consistently becomes agitated off sedation, as this represents a clinical reality requiring surrogate involvement
• Avoid asking "What do you want us to do?"—instead ask "What would the patient want?" or "What did the patient value most about their life?" to properly frame substituted judgment 1