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

Summary and Conclusions

Surrogate decision-making for long-term care facility residents will increase in frequency as the population ages. Decisions made by guardians and other surrogates should be ethically sound and based upon the best available clinical evidence. Health care providers have a responsibility to keep surrogates informed, to communicate information about prognosis and changes in condition, to provide guidance, and to work closely together with surrogates to foster decision-making in the best interest of the patient. Using all the available information from all involved persons, surrogates should be available to make decisions promptly, be willing to accept that treatment of some conditions may be ineffective or futile, be willing to forego ineffective treatments, and engage in advance care planning. Advance care planning may help to prevent delays in decision-making, and prevent undesired or futile treatments. Health care providers should familiarize themselves with the statutes and regulations pertaining to surrogate decision-making in their states.

Before patients become incapacitated, health care providers should encourage the completion of advance directives, including a living will and the naming of a surrogate decision maker (as in a DPOAHC), and should encourage patients to discuss their preferences and goals of care with whomever they have designated as surrogates. Health care providers, regulatory agencies, and public guardians should work together to clarify these issues and sponsor joint educational efforts. Because the legal framework for surrogate decision-making varies state by state, state-specific collaborations will be necessary to improve decision-making and outcomes for these vulnerable populations.
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