Advance Care Planning Series – #2 The Health Care Surrogate

Counselling on Selection of a Health Care Agent (Surrogate): Anyone can be chosen by the individual to be their healthcare agent with three exceptions:

  • Patient’s supervising healthcare provider unless related to the patient
  • Any employee of the healthcare institution where the patient receives care unless related to the patient
  • Any operator or employee of the facility where the patient lives unless related to the patient

The optimal healthcare agent should be willing and able to serve (assess the capability of the surrogate as well as the patient), knows the patients values and preferences, is able to make difficult decisions, and is willing and capable of speaking for the patient. The scope of authority of a healthcare agent includes:

  • Choosing a healthcare provider
  • Approving or refusing medical treatment
  • Agreeing to testing
  • Reviewing medical records
  • Donating organs
  • Authorizing autopsy
  • Directing the disposition of remains

The legal standard for surrogate decision making is either in accordance with the expressed wishes of the patient (substituted judgement) or if wishes are unknown, based upon the values and preferences of the patient. This means decisions are made as if the surrogate were standing in the shoes of the patient, making the decisions the patient would have made.

To name a healthcare agent, assist the patient in writing in the name, address, phone number and other contact information (eg. email address) for the primary surrogate. Also assist the patient in considering and putting in writing a backup or secondary surrogate if the primary is not available.

If the patient has not designated a healthcare agent, should they become incapacitated, the default surrogate is activated. These default agents include the spouse or domestic partner, and adult sibling, an adult child, an adult grandchild, or an adult relative with the closest degree of kinship. In a skilled nursing facility, the default surrogate is the attending physician.

Leeway is the degree of autonomy granted to the surrogate in making decisions for the patient. A patient can decide not to grant leeway meaning the surrogate must follow strictly the wishes of the patient. In other circumstance, the patient may decide to grant partial or full autonomy or leeway to the surrogate to use their judgement.

A section of the Advanced Directive allows the patient to determine if the surrogacy is immediately active or is only activated when a physician determines there is loss of capacity of the patient. Note the term ‘competence’ is not used as it is a legal term and is determined by a court.

Counselling on Living Will: A living will is the component of the advanced directive that provides guidance to the surrogate on what values and wishes that patient has about their continuing care. It make include:

  • What makes life worth living
  • Where the patient wants to die
  • The role of religion or spirituality in the dying process
  • Desire or lack thereof for supportive treatments
    • Life support including CPR, feeding tubes, dialysis, blood transfusion, artificial ventilation
  • Donation of patient’s organs
  • Preference for autopsy

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