Governance









White Paper on Surrogate Decision-Making and Advance Care Planning in Long-Term Care

Table of Contents
  1. Introduction
  2. Competence
  3. Decision-Making Capacity
  4. A framework for assessing decision-making capacity
  5. Surrogate Decision-Making
  6. Advance Directives
  7. Guardianship
  8. An Ethical Framework for Surrogate Decision-Making
  9. Decision-making by mentally incapacitated long-term care facility residents
  10. The hierarchy of medical decision-making for incapacitated nursing home residents
  11. Guidance for guardians and other surrogates about medical decision-making
  12. What surrogates and health care provider should expect from each other
  13. Some Important Clinical Issues
  14. Summary and Conclusions
  15. References

Introduction

Many residents of nursing facilities and other long-term care settings are cognitively impaired and thus may be incapable of making decisions about their medical care. Clinicians providing care for these residents must rely on previously specified advance directives or on other designated decision-makers, usually called surrogates, for guidance in medical decision-making. Because advance directives can explicitly address only a limited number of situations, and because for each incapacitated patient there are usually many decisions to make over time, continuing communication between the medical providers and surrogates is often necessary. Understanding the nature of advance care planning and surrogate decision-making is thus crucial for both health care providers and surrogates.

The terminology and laws pertaining to all aspects of surrogate decision-making vary greatly from state to state, and people involved in such decision-making must become familiar with their own state's statutes and language. What follows here is a general guide to surrogate decision-making, including that by guardians, and to the principles underlying it, along with recommendations on the subject from the American Medical Directors Association (AMDA). It is an overview of the subject, written with the understanding that some of the words used below may not be exactly those used in any individual's state of residence.

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