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Table of Contents
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
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54. Surrogate Decision-Making
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Excellence is never an accident. It always results from high intention, sincere effort, and intelligent execution; it represents the wise choice of many alternatives — choice, not chance, determines destiny.
~ Aristotle
Surrogate Choices
Surrogate Decision-Making in End-of-Life Care
Dr. Laura Carter had been a well-respected and successful neurosurgeon for over two decades. She had seen countless patients, and had become quite adept at understanding their needs, their wants, and their hopes. Dr. Carter’s latest patient was Mr. Johnson, a 65-year-old retired accountant who had been diagnosed with a malignant brain tumor. After his diagnosis, Mr. Johnson had executed a durable power of attorney for healthcare, appointing his daughter, Lisa, as his medical decision-maker.
Dr. Carter had met with Lisa on several occasions to discuss her father’s treatment options. They had reviewed his diagnosis, prognosis, and the risks and benefits of each available treatment. Lisa had always seemed engaged and informed, and Dr. Carter had been pleased with the progress they were making. However, on this particular day, Dr. Carter noticed something different about Lisa.
As they sat down to review Mr. Johnson’s latest MRI, Lisa seemed anxious and distracted. Dr. Carter tried to engage her in their usual discussion of treatment options, but Lisa seemed hesitant and unsure. After a few minutes of awkward silence, Lisa finally spoke up.
“Dr. Carter, I’m just not sure what to do. I want to do what’s best for my father, but I’m not sure what he would want.”
Dr. Carter could see the pain and frustration in Lisa’s eyes. She knew all too well the weight that surrogates must bear in making medical decisions for their loved ones.
“I understand how difficult this must be for you, Lisa,” Dr. Carter said, placing a reassuring hand on her shoulder. “But we have to remember that the most important thing is to make decisions that align with your father’s reasonable goals, values, and priorities.”
Lisa nodded, but Dr. Carter could tell that she was still uncertain. She suggested that they take a break and reconvene in a few days to continue the discussion.
The next day, Dr. Carter received a call from Lisa. She was distraught and in tears.
“Dr. Carter, my father has taken a turn for the worse,” Lisa said, her voice trembling. “The doctors at the hospital say that he’s not going to make it through the night.”
Dr. Carter rushed to the hospital, where she found Lisa by her father’s bedside. Mr. Johnson was unresponsive, and the machines that monitored his vital signs beeped in a steady rhythm.
“I’m so sorry, Lisa,” Dr. Carter said, embracing her. “Is there anything I can do?”
Lisa shook her head, tears streaming down her face. “I just wish I knew what he would want,” she said, her voice barely above a whisper.
Dr. Carter took Lisa’s hand and led her to a quiet corner of the room.
“Lisa, I know this is a difficult time for you, but we have to remember that your father’s autonomy is still the prime directive in medicine,” Dr. Carter said. “Even though he can’t make decisions for himself, we have to make sure that we’re making decisions that align with his reasonable goals, values, and priorities.”
Lisa nodded, wiping away her tears. “I understand,” she said. “But how do we know what those are?”
Dr. Carter took a deep breath. “Well, Lisa, we have to look at all the information we have available to us. We have to consider your father’s medical history, his personal values and beliefs, and any conversations he may have had with you or other family members about his wishes for end-of-life care.”
Lisa nodded, seeming to find some comfort in Dr. Carter’s words.
As the night wore on, Mr. Johnson’s condition continued to deteriorate. Dr. Carter and Lisa stayed by his side, holding his hand and trying to provide comfort as much as they could. At around 2 a.m., Mr. Johnson’s heart rate dropped significantly, and he started to gasp for air. Dr. Carter immediately called for the nurse and requested for a code blue to be initiated.
The code blue team arrived within minutes, and Dr. Carter briefed them on Mr. Johnson’s condition and medical history. Lisa stood in the corner, trying to stay out of the way while still observing the events unfold.
Despite the team’s best efforts, they were unable to resuscitate Mr. Johnson, and he was pronounced dead at 2:30 a.m. Dr. Carter and Lisa were devastated, knowing how hard Mr. Johnson had fought to survive.
During the debriefing with the hospital staff, Dr. Carter emphasized the importance of surrogate decision-making and how it can affect the patient’s quality of life and end-of-life care. He reminded his colleagues that their primary responsibility is to the patient and their best interests, even when the decisions are difficult.
In the end, Dr. Carter and Lisa knew that they had done everything they could to provide her father with the best possible care during his final days. Although they were saddened by his passing, they took solace in knowing that he had passed peacefully, with his wishes and values respected and honored until the end.
Abstract
The patient’s autonomy is the prime directive in medicine, with the patient being in the best position to determine their own best interests. In cases where the patient lacks decisional capacity, a durable power of attorney for health care is used to determine the surrogate who will make medical decisions on the patient’s behalf. The surrogate must make decisions based on the patient’s reasonable goals, values, and priorities and must be informed about the diagnosis, prognosis, treatment options, risks, and benefits. The medical practitioner has a professional responsibility to maximize the patient’s best interests and use the moral principles of beneficence (do good) and nonmaleficence (do no harm). If differences cannot be resolved, an ethics consultation is the next step, with a court order being necessary in some cases. The medical standards of care must be followed if there is no evidence of the patient’s reasonable goals, values, and priorities. With minors, the practitioner, surrogate, and state have the interest of protecting and maximizing the minor patient’s best interests as determined by medical standards of care. The Self-Determination Act of 1990 supports both patient informed consent and surrogate decision-making.
**
Think
[54:1] Medicine’s prime directive is to maximize the patient’s best interests as determined by the patient’s reasonable goals, values, and priorities. Since the Age of Enlightenment, liberalism, as espoused by John Locke, has bolstered the position that patients not only have individual rights and liberties of self-determination but that patients are in the best position for determining what will maximize their own best interests.
[54:2] But situations can occur when the patient no longer has decisional capacity and has no written living will to document and instruct what treatment options should be chosen or pursued. Without specific patient instructions in the medical records and without a living will, the next level of authority is the durable power of attorney for health care (POA). The durable power of attorney for health care (POA) is a legal document that delineates who will be the patient’s surrogate for making medical decisions on their behalf if they lose decisional capacity.
[54:3] If there is no durable power of attorney for health care (POA), then decisional authority will be sought typically in the following order:
- 1. guardian,
- 2. spouse,
- 3. adult offspring,
- 4. either parent,
- 5. any adult sibling,
- 6. any adult grandchild,
- 7. close friend,
- 8. guardian of the estate,
- 9. temporary custodian.
[54:4] The order of the list is based on the assumption that those higher up on the list will be in a better position to represent the patient’s best interests. The goal of the surrogate is not to make decisions based on what the surrogate themselves would do or based on the surrogate’s values, goals, and priorities; rather, the surrogate must make decisions as if the surrogate were the patient using the patient’s reasonable goals, values, and priorities.
Assess
Patient: 1) Autonomy
[54:5] If a patient lacks decisional capacity and has no documented decisional wishes in the medical record and no living will, then a surrogate will be determined by a durable power of attorney for health care (POA) and if that does not exist then through the use of a state-determined prioritized list. The goal is for the surrogate to make an informed consent decision as close as possible to what the patient would have made if they still had decisional capacity.
[54:6] This means that just like the patient, the surrogate must be substantially informed about the diagnosis, prognosis, treatment options, risks and benefits, and have the opportunity to have all their questions answered. This is why practitioners should encourage the patient to allow the surrogate to be part of the patient-practitioner relationship before the patient loses their decisional capacity, so that the surrogate can gain better understanding as to how the patient would like their medical decisions made.
Practitioner: 2) Beneficence & 3) Nonmaleficence
[54:7] The medical practitioner’s professional responsibility is the same as the surrogate’(s) responsibility concerning maximizing the patient’s best interests in accordance with the patient’s reasonable goals, values, and priorities. The practitioner’s and surrogate’(s) obligations are also to use the moral principles of beneficence (do good) and nonmaleficence (do no harm) when making decisions on the patient’s behalf.
[54:8] If the medical practitioner and surrogate have unresolvable differences and disagree on what the patient would have chosen during this collaborative decision-making process, then an ethics consultation would be the next step to take. If that does not resolve the issue, then perhaps a court order might be necessary. The extent to which the practitioner must pursue other decisional mandates for the protection of the patient is context-determined.
[54:9] If there is no evidence of the adult patient’s reasonable goals, values, and priorities, then the medical practitioner and patient’s surrogate are obliged to default to the medical standards of care. If two or more surrogates, at the same level of decisional authority, cannot agree on what medical decision should be made for the patient, then that also is when an ethics consult could be of benefit. Although ethics consults are only recommending bodies, and not decision-makers, ethics consults will provide an outside perspective, clarify surrogate misunderstandings, and help the surrogates focus on their decision-making rationale.
[54:10] Minor patients have never been legally competent, and therefore, there are no reasonable goals, values, and priorities of the patient to appeal to for decision-making. With minors, the practitioner, surrogate, and the state, have the interest to protect and maximize the minor patient’s best interests, as determined by medical standards of care. If medical standards of care is violated, then the practitioner has a professional, legal, and ethical obligation to intervene through the use of an ethics consultation, institutional reporting, and, if necessary, a court order for the protection of the minor patient.
Public Policy: 4) Justice
[54:11] The Self-Determination Act of 1990 was put in place for making sure that patients were aware of their right to make informed decisions, with practitioners regularly inquiring as to whether or not a patient has executed an advance directive, and if executed, making sure that the directive has been documented in the patient’s medical record. As much as public policy has supported the liberal notion of patient informed consent for the authorization of a practitioner to provide treatment, public policy has also supported surrogate decision-making.
Conclude
[54:12] The medical practitioner must inform the surrogate of all relevant information, as if they were the patient, and ensure, as much as possible, that the medical decision of the surrogate is what the patient would have chosen for themself, not what the surrogate would choose if they were to be in that situation.
[54:13] In summary, when a patient lacks decision-making capacity, a durable power of attorney for healthcare is used to determine a surrogate who will make medical decisions on their behalf based on the patient’s reasonable goals, values, and priorities. Surrogates must be informed about the diagnosis, prognosis, treatment options, risks, and benefits. The medical practitioner has a professional responsibility to maximize the patient’s best interests and use the moral principles of beneficence and nonmaleficence. If differences cannot be resolved, an ethics consultation is the next step, with a court order being necessary in some cases. The Self-Determination Act of 1990 supports both patient informed consent and surrogate decision-making.
**
54. Review Questions
1. Without specific patient instructions in the medical records and without a living will, the next level of authority is the durable power of attorney for health care (POA).
2. The goal of the surrogate is to make decisions as if the surrogate were the patient using the patient’s reasonable goals, values, and priorities.
3. Just like the patient, the surrogate must be substantially informed about the diagnosis, prognosis, treatment options, risks and benefits and have the opportunity to have all the surrogate’s questions answered.
4. The practitioner’s and surrogate’(s) responsibility is to maximize the patient’s best interests in accordance with the patient’s reasonable goals, values, and priorities.
5. If two or more surrogates, at the same level of decisional authority, cannot agree on what medical decision should be made for the patient, then that is when an ethics consult can be beneficial.
6. Ethics consults are decision-making bodies requiring compliance from the practitioner and surrogate.
**
CORRECT! 🙂
[54:2] But situations can occur when the patient no longer has decisional capacity and has no written living will to document and instruct what treatment options should be chosen or pursued. Without specific patient instructions in the medical records and without a living will, the next level of authority is the durable power of attorney for health care (POA). The durable power of attorney for health care (POA) is a legal document that instructs who will be the patient’s surrogate for making medical decisions on their behalf if they lose decisional capacity.
Wrong 😕
[54:2] But situations can occur when the patient no longer has decisional capacity and has no written living will to document and instruct what treatment options should be chosen or pursued. Without specific patient instructions in the medical records and without a living will, the next level of authority is the durable power of attorney for health care (POA). The durable power of attorney for health care (POA) is a legal document that instructs who will be the patient’s surrogate for making medical decisions on their behalf if they lose decisional capacity.
CORRECT! 🙂
[54:4] The order of the list is based on the assumption that those higher up on the list will be in a better position to represent the patient’s best interests. The goal of the surrogate is not to make decisions based on what the surrogate would do or based on the surrogate’s values, goals, and priorities; rather, the surrogate must make decisions as if the surrogate were the patient using the patient’s reasonable goals, values, and priorities.
Wrong 😕
[54:4] The order of the list is based on the assumption that those higher up on the list will be in a better position to represent the patient’s best interests. The goal of the surrogate is not to make decisions based on what the surrogate would do or based on the surrogate’s values, goals, and priorities; rather, the surrogate must make decisions as if the surrogate were the patient using the patient’s reasonable goals, values, and priorities.
CORRECT! 🙂
[54:6] This means that just like the patient, the surrogate must be substantially informed about the diagnosis, prognosis, treatment options, risks and benefits and have the opportunity to have all the surrogate’s questions answered. This is why practitioners should encourage the patient to allow the surrogate to be part of the patient-practitioner relationship before the patient loses their decisional capacity so that the surrogate can gain better understanding as to how the patient would like their medical decisions made.
Wrong 😕
[54:6] This means that just like the patient, the surrogate must be substantially informed about the diagnosis, prognosis, treatment options, risks and benefits and have the opportunity to have all the surrogate’s questions answered. This is why practitioners should encourage the patient to allow the surrogate to be part of the patient-practitioner relationship before the patient loses their decisional capacity so that the surrogate can gain better understanding as to how the patient would like their medical decisions made.
Wrong 😕
[54:7] The practitioner’s professional responsibility is the same as the surrogate’(s) responsibility concerning maximizing the patient’s best interests in accordance with the patient’s reasonable goals, values, and priorities. The practitioner’s and surrogate’(s) obligations are also to use the moral principles of beneficence (do good) and nonmaleficence (do no harm) when making decisions on the patient’s behalf.
CORRECT! 🙂
[54:7] The practitioner’s professional responsibility is the same as the surrogate’(s) responsibility concerning maximizing the patient’s best interests in accordance with the patient’s reasonable goals, values, and priorities. The practitioner’s and surrogate’(s) obligations are also to use the moral principles of beneficence (do good) and nonmaleficence (do no harm) when making decisions on the patient’s behalf.
Wrong 😕
[54:9] If there is no evidence of the adult patient’s reasonable goals, values, and priorities, then the practitioner and surrogate are obliged to default to the medical standards of care. If two or more surrogates, at the same level of decisional authority, cannot agree on what medical decision should be made for the patient, then that also is when an ethics consult can benefit. Although ethics consults are only recommending bodies, not decision-makers, ethics consults will provide an outside perspective, clarify surrogate misunderstandings, and help the surrogates focus on their decision-making rationale.
CORRECT! 🙂
[54:9] If there is no evidence of the adult patient’s reasonable goals, values, and priorities, then the practitioner and surrogate are obliged to default to the medical standards of care. If two or more surrogates, at the same level of decisional authority, cannot agree on what medical decision should be made for the patient, then that also is when an ethics consult can benefit. Although ethics consults are only recommending bodies, not decision-makers, ethics consults will provide an outside perspective, clarify surrogate misunderstandings, and help the surrogates focus on their decision-making rationale.
CORRECT! 🙂
[54:9] If there is no evidence of the adult patient’s reasonable goals, values, and priorities, then the practitioner and surrogate are obliged to default to the medical standards of care. If two or more surrogates, at the same level of decisional authority, cannot agree on what medical decision should be made for the patient, then that also is when an ethics consult can benefit. Although ethics consults are only recommending bodies, not decision-makers, ethics consults will provide an outside perspective, clarify surrogate misunderstandings, and help the surrogates focus on their decision-making rationale.
Wrong 😕
[54:9] If there is no evidence of the adult patient’s reasonable goals, values, and priorities, then the practitioner and surrogate are obliged to default to the medical standards of care. If two or more surrogates, at the same level of decisional authority, cannot agree on what medical decision should be made for the patient, then that also is when an ethics consult can benefit. Although ethics consults are only recommending bodies, not decision-makers, ethics consults will provide an outside perspective, clarify surrogate misunderstandings, and help the surrogates focus on their decision-making rationale.
54. Clinical Vignettes
1. Ms. Lily Reed is a 72-year-old retired teacher who was admitted to the hospital with severe heart failure. Despite initial interventions, her condition has worsened, and she is now experiencing multi-organ failure. She has been intubated and placed on a ventilator, and her medical team has determined that she lacks decisional capacity. Ms. Reed has no living will or advanced directive, but her daughter has been designated as her durable power of attorney for healthcare (POA). The medical team has explained to the daughter that her mother's prognosis is poor and that she is unlikely to survive without life-sustaining measures. The daughter, however, is deeply religious and believes that it is not her place to end her mother's life. The ethical question is whether to follow the daughter's wishes or transition Ms. Reed to comfort measures.
2. Ms. Ana Hill is a 60-year-old retired nurse who was admitted to the hospital after experiencing chest pain, shortness of breath, and fatigue. Initial assessments suggest that Ms. Hill might have congestive heart failure or a pulmonary embolism. She has two adult children, both of whom are listed as having equal decisional authority as her healthcare surrogates. However, Ms. Hill's children cannot agree on what medical decision to make regarding their mother's care. One believes that their mother would want to receive aggressive treatment to prolong her life, while the other thinks that their mother would not want to go through invasive interventions if her condition worsens. An ethics consultation is called to help Ms. Hill's children reach a consensus on the best course of action for their mother's care.
3. Ms. Victoria Wyatt is a 68-year-old retired school teacher who is admitted to the hospital with acute respiratory distress syndrome. She is intubated and placed on a ventilator. Ms. Wyatt has no advance directives or surrogate decision-maker identified. The medical team has exhausted all treatment options and the patient is not responding to therapy. The medical team believes that it is time to consider end-of-life care. The ethical question in this case is who should make the decision for Ms. Wyatt, given that she lacks decisional capacity, has no advance directives or identified surrogate decision-maker, and the medical team is recommending end-of-life care.
4. Ms. Julia Allen is a 70-year-old retired teacher who has been diagnosed with advanced lung cancer. She has been hospitalized for severe respiratory distress and is not able to make her own medical decisions. She has no durable power of attorney for healthcare (POA) and no known family members. The medical team is considering the use of AI surrogate decision-making to determine her medical care. What is the ethical question in this scenario?
5. Ms. Rachel Taylor is a 70-year-old retired teacher who has been diagnosed with advanced lung cancer. She has been hospitalized for severe respiratory distress and is not able to make her own medical decisions. She has no durable power of attorney for healthcare (POA) and no known family members. The medical team is considering the use of telemedicine to connect with a surrogate decision-maker who is located in a different country. What is the ethical question in this scenario?
CORRECT! 🙂
Explanation: In the absence of specific patient instructions in the medical record and a living will, the durable power of attorney for healthcare (POA) is the next level of authority in decision-making [54:2]. The surrogate must make decisions based on the patient’s reasonable goals, values, and priorities and must be informed about the diagnosis, prognosis, treatment options, risks, and benefits [54:4]. In this case, the daughter has been designated as the surrogate and has the legal authority to make decisions on behalf of her mother. If differences cannot be resolved, an ethics consultation is the next step [54:9]. The ethics committee can help identify ethical issues, clarify misunderstandings, and provide guidance on relevant policies and laws [54:9]. However, the decision-making authority remains with the surrogate(s) unless there are unresolvable differences between the surrogate(s) and the medical practitioner, in which case a court order may be necessary [54:8]. In this case, the daughter's deeply held religious beliefs conflict with the medical team's recommendations to transition Ms. Reed to comfort measures [54:1]. While it may be appropriate for the medical team to continue to educate the daughter about the risks and benefits of continuing aggressive measures, ultimately the decision lies with the surrogate, and following the daughter's wishes to continue all life-sustaining measures would be the correct course of action.
Wrong 😕
Explanation: In the absence of specific patient instructions in the medical record and a living will, the durable power of attorney for healthcare (POA) is the next level of authority in decision-making [54:2]. The surrogate must make decisions based on the patient’s reasonable goals, values, and priorities and must be informed about the diagnosis, prognosis, treatment options, risks, and benefits [54:4]. In this case, the daughter has been designated as the surrogate and has the legal authority to make decisions on behalf of her mother. If differences cannot be resolved, an ethics consultation is the next step [54:9]. The ethics committee can help identify ethical issues, clarify misunderstandings, and provide guidance on relevant policies and laws [54:9]. However, the decision-making authority remains with the surrogate(s) unless there are unresolvable differences between the surrogate(s) and the medical practitioner, in which case a court order may be necessary [54:8]. In this case, the daughter's deeply held religious beliefs conflict with the medical team's recommendations to transition Ms. Reed to comfort measures [54:1]. While it may be appropriate for the medical team to continue to educate the daughter about the risks and benefits of continuing aggressive measures, ultimately the decision lies with the surrogate, and following the daughter's wishes to continue all life-sustaining measures would be the correct course of action.
CORRECT! 🙂
Explanation: An ethics consultation can be beneficial in situations where surrogates with equal decisional authority cannot agree on what medical decision to make for a patient [54:9]. The role of the ethics consult is not to make the decision for the surrogates, but rather to provide recommendations and help the surrogates come to a consensus on the best course of action for the patient [54:9]. The other options are wrong because the ethics consult does not make the decision for the surrogates, rather they are only a recommending body [54:9], both surrogates are listed as having equal decisional authority [54:4], and a court order is typically only necessary in extreme cases where there is a significant risk of harm to the patient [54:8].
Wrong 😕
Explanation: An ethics consultation can be beneficial in situations where surrogates with equal decisional authority cannot agree on what medical decision to make for a patient [54:9]. The role of the ethics consult is not to make the decision for the surrogates, but rather to provide recommendations and help the surrogates come to a consensus on the best course of action for the patient [54:9]. The other options are wrong because the ethics consult does not make the decision for the surrogates, rather they are only a recommending body [54:9], both surrogates are listed as having equal decisional authority [54:4], and a court order is typically only necessary in extreme cases where there is a significant risk of harm to the patient [54:8].
Wrong 😕
Explanation: In the absence of an identified surrogate decision-maker or advance directives, the state-appointed surrogate decision-maker should make the decision [54:5]. The surrogate decision-maker is responsible for making decisions based on the patient’s reasonable goals, values, and priorities [54:4]. If the surrogate cannot be identified or located, the medical team may petition the court to appoint a surrogate [54:3]. It is not appropriate for the medical team to make the decision to withdraw care without a surrogate decision-maker or court order [54:1]. While the hospital ethics committee may provide guidance and consultation, they are not responsible for making any decisions [54:9]. In the end, the ethical principle of patient autonomy is upheld by ensuring that the appointed surrogate decision-maker is making decisions in accordance with the patient’s reasonable goals, values, and priorities, and if that is not known then by focusing on the patient’s best interests in accordance with medical standards of care [54:4] [54:9].
CORRECT! 🙂
Explanation: In the absence of an identified surrogate decision-maker or advance directives, the state-appointed surrogate decision-maker should make the decision [54:5]. The surrogate decision-maker is responsible for making decisions based on the patient’s reasonable goals, values, and priorities [54:4]. If the surrogate cannot be identified or located, the medical team may petition the court to appoint a surrogate [54:3]. It is not appropriate for the medical team to make the decision to withdraw care without a surrogate decision-maker or court order [54:1]. While the hospital ethics committee may provide guidance and consultation, they are not responsible for making any decisions [54:9]. In the end, the ethical principle of patient autonomy is upheld by ensuring that the appointed surrogate decision-maker is making decisions in accordance with the patient’s reasonable goals, values, and priorities, and if that is not known then by focusing on the patient’s best interests in accordance with medical standards of care [54:4] [54:9].
CORRECT! 🙂
Explanation: The ethical question in this scenario is whether it is ethical to use AI surrogate decision-making to determine Ms. Allen's medical care [54:5]. While the use of AI technology can potentially assist in making medical decisions, it raises ethical concerns related to patient autonomy, beneficence, and non-maleficence [54:7]. AI may not be able to fully consider the patient's individual circumstances, values, and goals, which could potentially result in decisions that are not in the patient's best interests [54:1]. Additionally, the use of AI technology in surrogate decision-making raises questions about who is ultimately responsible for the decision and the potential for legal and ethical conflicts [54:2]. Therefore, it is important for medical practitioners to consider the limitations and ethical implications of using AI in surrogate decision-making, and to ensure that any decisions made are in line with the patient's goals and values [54:6]. For example, who would be responsible if an AI system made a decision that resulted in harm to the patient? Would the responsibility lie with the developer of the AI system, the healthcare provider who used it, or the surrogate decision-maker who relied on the AI system [54:2]? Additionally, how can we ensure that the AI system is taking into account the patient's reasonable goals, values, and priorities in the same way a human surrogate decision-maker would [54:6]? Furthermore, the use of AI in healthcare decision-making also raises concerns about the potential for bias and discrimination in the decision-making process [54:4]. For instance, if an AI system is trained on data that is biased against certain patient groups, it may produce decisions that perpetuate that bias [54:4]. Overall, while the use of AI in surrogate decision-making is still in its early stages, it is important for healthcare providers and policymakers to carefully consider the ethical and legal implications of this technology in order to ensure that patient autonomy and best interests are upheld [54:12]. The medical practitioner must inform the surrogate of all relevant information, as if they were the patient, and ensure, as much as possible, that the medical decision of the surrogate is what the patient would have chosen for themselves, not what the surrogate would choose if they were to be in that situation [54:12].
Wrong 😕
Explanation: The ethical question in this scenario is whether it is ethical to use AI surrogate decision-making to determine Ms. Allen's medical care [54:5]. While the use of AI technology can potentially assist in making medical decisions, it raises ethical concerns related to patient autonomy, beneficence, and non-maleficence [54:7]. AI may not be able to fully consider the patient's individual circumstances, values, and goals, which could potentially result in decisions that are not in the patient's best interests [54:1]. Additionally, the use of AI technology in surrogate decision-making raises questions about who is ultimately responsible for the decision and the potential for legal and ethical conflicts [54:2]. Therefore, it is important for medical practitioners to consider the limitations and ethical implications of using AI in surrogate decision-making, and to ensure that any decisions made are in line with the patient's goals and values [54:6]. For example, who would be responsible if an AI system made a decision that resulted in harm to the patient? Would the responsibility lie with the developer of the AI system, the healthcare provider who used it, or the surrogate decision-maker who relied on the AI system [54:2]? Additionally, how can we ensure that the AI system is taking into account the patient's reasonable goals, values, and priorities in the same way a human surrogate decision-maker would [54:6]? Furthermore, the use of AI in healthcare decision-making also raises concerns about the potential for bias and discrimination in the decision-making process [54:4]. For instance, if an AI system is trained on data that is biased against certain patient groups, it may produce decisions that perpetuate that bias [54:4]. Overall, while the use of AI in surrogate decision-making is still in its early stages, it is important for healthcare providers and policymakers to carefully consider the ethical and legal implications of this technology in order to ensure that patient autonomy and best interests are upheld [54:12]. The medical practitioner must inform the surrogate of all relevant information, as if they were the patient, and ensure, as much as possible, that the medical decision of the surrogate is what the patient would have chosen for themselves, not what the surrogate would choose if they were to be in that situation [54:12].
CORRECT! 🙂
Explanation: The ethical question in this scenario is whether it is ethical to use telemedicine to connect with a surrogate decision-maker who is located in a different country [54:5]. While the use of telemedicine can potentially assist in making medical decisions, it raises ethical concerns related to patient autonomy, beneficence, and non-maleficence [54:7]. The surrogate decision-maker may not be familiar with the healthcare system or cultural norms of the country where the patient is receiving care, which could potentially result in decisions that are not in the patient's best interests [54:1]. Additionally, the use of telemedicine in surrogate decision-making raises questions about who is ultimately responsible for the decision and the potential for legal and ethical conflicts [54:2]. Therefore, it is important for medical practitioners to consider the limitations and ethical implications of using telemedicine in surrogate decision-making, and to ensure that any decisions made are in line with the patient's goals and values [54:6]. For example, who would be responsible if the surrogate made a decision that resulted in harm to the patient? Would the responsibility lie with the healthcare provider who facilitated the telemedicine connection, or the surrogate decision-maker who relied on the telemedicine system? Furthermore, the use of telemedicine in healthcare decision-making also raises concerns about the quality and security of the communication [54:4]. For instance, if the telemedicine connection is disrupted or insecure, it may affect the quality of the communication and the accuracy of the decision-making process [54:4]. Overall, while the use of telemedicine in surrogate decision-making is becoming more common, it is important for healthcare providers and policymakers to carefully consider the ethical and legal implications of this technology in order to ensure that patient autonomy and best interests are upheld [54:12]. The medical practitioner must inform the surrogate of all relevant information, as if they were the patient, and ensure, as much as possible, that the medical decision of the surrogate is what the patient would have chosen for themselves, not what the surrogate would choose if they were to be in that situation [54:12].
Wrong 😕
Explanation: The ethical question in this scenario is whether it is ethical to use telemedicine to connect with a surrogate decision-maker who is located in a different country [54:5]. While the use of telemedicine can potentially assist in making medical decisions, it raises ethical concerns related to patient autonomy, beneficence, and non-maleficence [54:7]. The surrogate decision-maker may not be familiar with the healthcare system or cultural norms of the country where the patient is receiving care, which could potentially result in decisions that are not in the patient's best interests [54:1]. Additionally, the use of telemedicine in surrogate decision-making raises questions about who is ultimately responsible for the decision and the potential for legal and ethical conflicts [54:2]. Therefore, it is important for medical practitioners to consider the limitations and ethical implications of using telemedicine in surrogate decision-making, and to ensure that any decisions made are in line with the patient's goals and values [54:6]. For example, who would be responsible if the surrogate made a decision that resulted in harm to the patient? Would the responsibility lie with the healthcare provider who facilitated the telemedicine connection, or the surrogate decision-maker who relied on the telemedicine system? Furthermore, the use of telemedicine in healthcare decision-making also raises concerns about the quality and security of the communication [54:4]. For instance, if the telemedicine connection is disrupted or insecure, it may affect the quality of the communication and the accuracy of the decision-making process [54:4]. Overall, while the use of telemedicine in surrogate decision-making is becoming more common, it is important for healthcare providers and policymakers to carefully consider the ethical and legal implications of this technology in order to ensure that patient autonomy and best interests are upheld [54:12]. The medical practitioner must inform the surrogate of all relevant information, as if they were the patient, and ensure, as much as possible, that the medical decision of the surrogate is what the patient would have chosen for themselves, not what the surrogate would choose if they were to be in that situation [54:12].
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54. Reflection Vignettes
1. Dr. Olivia Lee, a 45-year-old attending practitioner, is caring for a patient in the ICU who lacks decisional capacity. The patient's surrogate has been making medical decisions, but Dr. Lee believes that the surrogate is making decisions based on their own goals, values, and priorities, rather than the patient's. As a medical practitioner, Dr. Lee understands that the prime directive in medicine is to maximize the patient's best interests based on the patient's reasonable goals, values, and priorities. She recognizes that the surrogate must be informed about the diagnosis, prognosis, treatment options, risks, and benefits, and must make decisions based on what the patient would have chosen if they had decisional capacity. If differences cannot be resolved, an ethics consultation is the next step, with a court order being necessary in some cases. Dr. Lee knows that the medical standards of care must be followed if there is no evidence of the patient's reasonable goals, values, and priorities, and she is committed to ensuring that the patient's best interests are being served.
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
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2. Dr. Jane Miller, a 38-year-old family practitioner, sees a 65-year-old retired teacher named Susan Johnson in her office for a routine check-up. During the history and physical exam, Dr. Miller discovers that Ms. Johnson has not yet filled out an advance directive with a living will or durable power of attorney. As a responsible practitioner, Dr. Miller should explain the importance of advance directives to Ms. Johnson, clarify her understanding of what they are and their benefits, and provide her with the necessary forms and guidance to complete them. Dr. Miller can also refer Ms. Johnson to a social worker or other resources to help her make informed decisions about her medical care preferences and appoint a surrogate decision-maker. It is essential for Dr. Miller to respect Ms. Johnson's autonomy and ensure that she has the opportunity to exercise her right to make informed decisions about her healthcare.
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
**
54c*
A patient is on a ventilator in the ICU for severe pneumonia. The patient does not have decisional capacity, no oral or written preferences, no living will, and no durable power of attorney are on record. The patient’s condition continues to deteriorate. The patient’s older offspring wants to withdraw life-support, but the patient’s younger offspring disagrees. What should be done?
- A. Since the surrogates disagree, it is up to the practitioner to decide.
- B. Err on the side of life and keep providing life-support.
- C. Encourage discussion and help the surrogates form a consensus.
- D. Get a court order to appoint an independent proxy.
- E. Get hospital risk management involved and have them assess the situation.
Think
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
***
