Many state laws specify procedures for determining surrogate or proxy decision-makers for end-of-life care in the absence of an advance directive, living will, or other designation. Some laws also set forth criteria that the decision-maker must follow when making medical decisions for an incapacitated patient and determining whether to withdraw life-sustaining treatment. This article provides analysis of a medical ethics case on the question of how to address family allegations that the proxy decision-maker suffers from dementia and is unable to make decisions for the patient. Cases such as this involve interwoven legal and ethical considerations including: how to address concerns that the proxy is making questionable or unreasonable decisions, how to evaluate the proxy's decisional capacity, strategies for enhancing communication, and standards for removing a proxy. This article suggests that “surrogacy ladders” in state law serve not only as a procedural mechanism, but also protect important ethical values such as tiers of moral authority for decision-making, relational autonomy, and privacy.
American Bar Association Commission on Law and Aging. Default Surrogate Consent Statutes. American Bar Assocation. 2022. https://www.americanbar.org/content/dam/aba/administrative/law_aging/2019-sept-default-surrogate-consent-statutes.pdf.
LuceJM. A history of resolving conflicts over End-of-life care in intensive care units in the United States. Crit Care Med2010; 38: 1623–1629.
4.
VenkatABeckerJ. The effect of statutory limitations on the authority of substitute decision makers on the care of patients in the intensive care unit. J Intensive Care Med2014; 29: 71–80.
5.
PopeTM. Legal fundamentals of surrogate decision making. Chest2012; 141: 1074–1081.
DeMartinoESDudzinskiDMDoyleCK, et al.Who decides when a patient can’t? Statutes on alternate decision-makers. N Engl J Med2017; 376: 1478–1482.
8.
Florida Code Ann. § 765.401. http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0700-0799/0765/0765.html.
9.
KimHDeatrickJA. Ulrich CA ethical frameworks for Surrogates’ End-of-life planning experiences. Nurs Ethics2017; 24: 46–69.
10.
BatteuxEFergusonETunneyRJ. On the likelihood of surrogates conforming to the substituted judgment standard when making End-of-life decisions for their partner. Med Decis Making2019; 39: 651–660.
11.
BatteuxEFergusonETunneyRJ. A mixed methods investigation of End-of-life surrogate decisions among older adults. BMC Palliat Care2020; 19: 44.
12.
AyalonLBachnerYGDwolatzkyT,et al.Preferences for End-of-life treatment: concordance between older adults with dementia or mild cognitive impairment and their spouses. Int Psychogeriatr2012; 24: 1798–1804.
13.
HulkowerAFlickerLS. It’s all relative. Hastings Center Report2018; 48: 43–44.
14.
MarksMAArkesHR. Patient and surrogate disagreement in End-of-life decisions: can surrogates accurately predict Patients’ preferences?Med Decis Making2008; 28: 524–531.
15.
WhiteDBMalvarGKarrJ, et al.Expanding the paradigm of the physician’s role in surrogate decision-making: an empirically derived framework. Crit Care Med2010; 38: 743–750.
16.
SkinnerTRScottIAMartinJH. Diagnostic errors in older patients: a systematic review of incidence and potential causes in seven prevalent diseases. Int J Gen Med2016; 9: 137–146.
17.
RogersSEThrasherADMiaoY, et al.Discrimination in healthcare settings is associated with disability in older adults: health and retirement study, 2008–2012. J Gen Intern Med2015; 30: 1413–1420.
18.
LevyBRSladeMDChangE, et al.Ageism amplifies cost and prevalence of health conditions. Gerontologist2020; 60: 174–181.
19.
ResnickLCowartMEKubrinA. Perceptions of do-not-resuscitate orders. Soc Work Health Care1998; 26: 1–21.
20.
GreeneMGAdelmanRDCharonR,et al.Concordance between physicians and their older and younger patients in the primary care medical encounter. Gerontologist1989; 29: 808–813.
21.
CuddyAJNortonMIFiskeST. This old stereotype: the pervasiveness and persistence of the elderly stereotype. Journal of Social Issues2005; 61: 267–285.
22.
DonohuePKNorvellMBossRD, et al.Hospital chaplains: through the eyes of parents of hospitalized children. J Palliat Med2017; 20: 1352–1358.
23.
PesutBSinclairSFitchettG, et al.Health care chaplaincy: a scoping review of the evidence 2009–2014. J Health Care Chaplain2016; 22: 67–84.
24.
AllenNMishkinA. The incapacitated surrogate: what is the consultation-liaison psychiatrist’s role?Psychosomatics2020; 61: 672–677.
25.
Florida Code Ann. § 765.105. http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0700-0799/0765/0765.html.
26.
MagoRKunkelEJSStinnettJ. Pearls in evaluating patient capacity to make medical decisions. Psychiatry2006; 3: 42–45. PMID: 21103154.
27.
BramstedtK. Questioning the decision-making capacity of surrogates. Intern Med J2003; 33: 257–259.
28.
SmithKLFedelPHeitmanJ. Incapacitated surrogates: a new and increasing dilemma in hospital care. Journal of Clinical Ethics2017; 28: 279–289. PMID: 29257763.
29.
VargheseRPatelKBurkeH, et al.Challenging a surrogate decision-maker: a case of an incapacitated patient following self-enucleation. Primary Care Companion CNS Disorders2022; 24: 21f03102.
30.
WhiteMMLofwallMR. Challenges of the capacity evaluation for the consultation-liaison psychiatrist. J Psychiatr Pract2015; 21: 160–170.
31.
LindemannH. The intimate responsibility of surrogate decision-making. Hastings Center Report2018; 48: 41–42.
32.
BrudneyD. The different moral bases of patient and surrogate decision-making. Hastings Center Report2018; 48: 37–41.
33.
LindemannH. The intimate responsibility of surrogate decision-making. Hastings Center Report2018; 48: 41–42.
34.
WassermanJANavinMC. Capacity for preferences: respecting patients with compromised decision-making. Hastings Center Report2018; 48: 31–39.
