Who Will Speak For You?

Legal Hierarchy in Georgia

For medical or surgical treatment decisions:

• Patient
• Healthcare Agent
• Spouse
• Guardian
• Adult Child
• Parent
• Adult Sibling
• Grandparent
• Grandchild
• Adult Niece, Nephew, Aunt, Uncle of first degree
• Adult Friend

For Do Not Resuscitate (DNR):

• Patient
• Healthcare Agent
• Spouse
• Guardian
• Adult Child
• Parent
• Adult Sibling

Regardless of who the surrogate decision maker (SDM) is or how they were appointed, there are certain expectations of him or her when making healthcare decisions.

First, if there is an advance directive which includes treatment preferences, then the SDM is expected to follow those preferences. It is also important that the SDM not make decisions based on their own preferences, but those of the patient.

As discussed earlier, there is an expectation that the SDM honor the patient’s wishes and be guided by those wishes when making decisions. The healthcare team is looking for the SDM to express what the patient’s wishes would be if they could speak for themselves. There are two ways to think about what to do when trying to make decisions:

Substituted Judgement

This means making the same decision that the patient would make if they could make the decision themselves. These decisions are made based on the patient’s values, goals and past behaviors.

Questions to help quide substituted decision-making:

• Did the patient talk about how he/she wanted to live or die?
• Did you talk to them about choices that other family members may have made in a similar situation?
• Did the patient ever talk about treatments that he/she would or would not want (breathing tube, feeding tube, etc.)?

Best-Interest Standard

This is used when the patient’s values, goals and past behaviors are unknown. This means making decisions that look at both the positive and negative sides of possible treatment(s). The SDM should think about what they want to happen and the likelihood of that happening with the available treatment options.

Questions to help guide Best-Interest decision making:

• Will this treatment help get the patient back to the way they were before they got sick?
• Will this treatment cause pain/suffering or possibly make them sicker?
• Will this treatment add days/months to their life? What will those days/months look like?
• Will this treatment harm the patient more than it will help?

When using the best-interest standard, best interest should be determined from the perspective of the patient, not that of the SDM.