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Patient Proxies

In the best interests of the patient. In accordance with the patient’s wishes. Preserving patient autonomy. These concepts are at the core of modern medical decision-making.

Traditionally medical decisions are made by hospitalists and communicated to patients. This approach has shifted to an emphasis on patient autonomy and input in decision-making.

But what about the patient unable to make decisions or provide input to the medical caregivers? How can the comatose or incompetent patient participate in his or her own care decisions? What happens when half of a team is no longer able to share team functions?

In these instances, hospitalists rely on surrogates. A surrogate is empowered not only to speak for but also to make legal decisions for a patient. The relationship becomes a triad of hospitalist, surrogate, and patient. This triad must include:

  • A hospitalist who brings the same degree of trust, respect, and open communication to the new relationship;
  • A surrogate who is an active participant rather than a passive spokesperson; and
  • A patient whose interests are the primary goal.

SURROGATE STEPS

  • Immediately begin building trust to develop understanding about the patient’s needs and wishes.
  • Maintain continuity and open lines of communication with the surrogate. Try to ensure that the surrogate continues talking with the same staff members.
  • Talk to the surrogate often about medical information. Do not allow the surrogate to make a decision without all the information available.
  • Speak to the surrogate in laymen’s terms. Be sure the surrogate understands the medical information about the patient’s status, what is possible, and what is recommended.
  • Consider the surrogate’s emotions and feelings from the beginning. Provide support and comfort. Ask about the surrogate’s values or viewpoint.
  • Call on multidisciplinary staff to facilitate interaction with surrogates whose cultural mores or language may cause confusion or conflict or whose emotions may be interfering with the task at hand.
  • Be prepared to rethink decision-making in light of surrogate and patient’s cultural values or religious beliefs.
  • Talk to the ethics committee early in the patient’s care; do not wait until you see a problem developing. Work within the internal system to prevent a judicial or legal intervention.
  • Do everything possible to avoid a judicial intervention or court guardianship of the patient. Consider this to be a last resort. It not only adds bureaucratic layers, but it also costs money.—AK

Key Issues

The aging of the population and the increased prevalence of medical conditions causing cognitive impairment point up the need to take a closer look at the hospitalist-surrogate relationship. A study this year outlined four key issues:

  • There are unique challenges for both parties in creating a hospitalist-surrogate relationship;
  • The hospitalist and surrogate are dealing not only with each other but also with the decision-making role each will play in regard to the patient;
  • The surrogate must understand that serving as a surrogate for a loved one is completely different from making decisions for oneself; and
  • There may be more than one surrogate decision maker.1

The first challenge facing hospitalist and surrogate is establishing a foundation of trust, respect, and a treatment plan. Their perspectives play a critical role: The surrogate knows the patient as a lively, engaged, and interesting individual, while the hospitalist has seen the patient only in a nonresponsive, incapacitated state. Opening an immediate line of communication is the best way to assume their respective responsibilities.

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