Abstract
Dear Editor:
“The consult is for goals of care, withdrawal of the ventilator, discontinuing tube feedings, and discussing DNR.”
“Any family?” I asked.
“There's usually a man in her room, not sure who he is, I've only been on service for two days. The family has refused a DNR or withdrawal of the vent. Sorry I don't know more.”
“Who's been giving consent for treatment?”
The medical resident shrugged.
Unfortunately, more often than not, the designated decision maker, particularly in an intensive care environment, is not the appropriate person. Whenever I am consulted, one of my first questions to the referring physician is: ‘Can the person make their own decisions, and if not, who is the family, who is the legal surrogate, and is there an advance directive?’ The answers can be astounding and disturbing, from the honest and self-effacing ‘I don't know, but I should’ to ‘There's a woman who is always in the room, that's who we've been speaking to and getting permission for treatment.’ The lack of due diligence in identifying a legal surrogate has become concerning as technology has enabled physicians to prolong life beyond what most would want, and patients clamor for shared decision making and patient-centered care. Moreover, in an increasingly cost-conscious, resource-burdened, and “less is more” clinical climate, the need to identify a legal surrogate is more important than ever.
That said, I have no doubt that physicians have a patient's best interest at heart when discussing or recommending treatment options. However, failure to speak with a legal surrogate denies patient autonomy and informed consent, and may result in treatments contrary to the patient's wishes. Moreover, medico-legal issues may arise when medical decisions are made by an unauthorized proxy. As a result, it is imperative that physicians identify a legal surrogate for health care decisions so that clinical errors may be avoided and the needs and wants of patients and families responsibly met.