Second, even after the hospitalist and surrogate develop an initial working relationship, they may still need to outline mutually satisfying ways to share decision-making with the patient. Both must balance their concern for the patient, their understanding of the patient’s status, and their perspectives of what the patient would want. With time pressures and the capabilities of modern technology, this mutual decision-making responsibility may seem daunting.
Third, surrogates may discover a conflict between their personal values and their patient’s. They may have to make a decision that reflects their patient’s wishes yet contradicts their own beliefs. Sometimes hospitalists can help the surrogate resolve this dilemma by suggesting consultations with other family members or professionals.
The fourth issue, multiple surrogates, may magnify the challenges but can also be an advantage. In most cases families, even those with members who have differing belief systems, tend to support each other during crises to reach a consensus in the patient’s best interests.
Tom Baudendistel, MD, a hospitalist at California Pacific Medical Center in San Francisco, says that although engaging in a dialogue with the multiple surrogates may reveal a family conflict, mistrust, or other issues, the problem is usually resolved. “One surrogate comes around after we make sure the one disagreeing sees in person what the patient is going through, the low quality of life,” says Dr. Baudendistel.
Howard Epstein, MD, medical director, Care Management and Palliative Care, Regions Hospital, St. Paul, Minn., suggests a different approach. “We ask the surrogate to imagine that if the patient could stand outside his or her body, hearing everything that is being said, what would he or she say?” says Dr. Epstein.
The Process
While these issues affect all hospitalists who work with surrogates, hospitalists often encounter additional circumstances that require special attention. These are not always problems but may be situations unique to the hospital setting or the hospitalist’s job.
The hospitalist’s first contact with a patient is often the patient’s admission to the hospital. The hospitalist is most often starting with a blank page with no background information. Gathering information quickly about an unknown patient is critical.
This duty often falls to hospitalists. Donald Krause, MD, medical director for quality assurance at St. Joseph Hospital in Bangor, Maine, and a hospitalist for 11 years, points out that “hospitalists take care of 90% of medical admissions and as part of this job arrange for surrogates if needed as well as anything else to help the patient.”
Beginning with the admission of a patient, the hospitalist may take on the responsibility of finding a surrogate.
Find a surrogate: When a patient is admitted, the hospitalist questions everyone connected to the patient about the existence of a surrogate or family spokesperson. If there is no information available, many hospitalists turn to other staff experts, such as social workers or chaplains, to seek people who know the patient.
Dr. Baudendistel says his medical center resuscitates “unbefriended” patients admitted to the emergency department to allow time to find a family member or surrogate. “Social workers then search the Internet, call shelters, and contact other hospitals and institutions to learn anything they can about the patient,” he says. If the search is unsuccessful, the hospitalist usually consults the institution’s ethics committee for additional suggestions.
Don C. Postema, PhD, ethics consultant for Regions Hospital, chair of the HealthPartners Ethics Committee, and ethicist-in-residence at Gillette Children’s Specialty HealthCare in St. Paul, Minn., proposes that an ethics committee look beyond the standard candidates in searching for a surrogate. “The legal relationship of a potential surrogate to the patient is secondary to what I consider to be the primary relationship, that is, the person who knows the patient best,” says Dr. Postema. “It could be the patient’s landlord or a neighbor who sees the patient on a regular basis.”