When mediation fails: identifying and working with inappropriate surrogate decision makers

Abstract

Patient autonomy and informed consent are cornerstones of medicine, though often clinicians interact directly with surrogate decision makers (SDMs) instead of patients when the latter is deemed incapacitated. Although most SDMs are able to fulfill their duty as proxies, incongruence between SDM role and behavior may occur, even after the best mediation efforts possible by various clinical teams. Instances in which SDMs act inappropriately in their role and fail to respond to such efforts by clinical teams warrant serious consideration of SDM replacement. We offer a case series of such instances, describe difficulties faced by SDMs in their role, and offer ethical and legal perspective regarding the challenging and removal of SDMs after thoughtful and collective deliberation.

Keywords:

• Surrogate decision maker
• Autonomy
• Decision-making capacity
• Ethics
• Substituted judgment
• Best interests