There are going to be two ways that
surrogate decision makers can make decisions
and you heard about this in the
informed consent lecture.
The two ways, the two standards are
substituted judgment and best interest.
Substituted judgment is when the patient,
again, can make their own decisions
but has communicated in some way their
preferences, their values to the surrogate.
So, the surrogate is then making decisions
based on their knowledge of who the patient is,
what their health condition is and can sort of
surmise based on their intimate knowledge of the patient
and their life, how they would
make particular medical decisions.
So, that's substituted judgement. If the patient has not communicated
those values and preferences to the surrogate,
then, the surrogate has to rely
on best interest standard
and that is you don't know what
substituted judgment would be.
In this particular circumstance, you don't
have an advanced directive to refer to.
You need to interpret best interest in light
of the current clinical situation.
So, the surrogate gathers all the information,
decides what's best on behalf of the patient,
all things considered based on what the,
you know, clinicians have communicated to them.
So, how do you figure out
what best interest is?
How is the surrogate going to figure out
what best interests are for the patient?
It's going to be both what is beneficial to the
patient as well as what would avoid harm to the patient.
This calculus of benefit and burden or harm has
to be weighed in by the surrogate decision maker.
The things that the clinician should encourage
the surrogate decision maker to factor
in when they're thinking about best interest,
number one would be things
like what are the effects of the treatment on the physical,
emotional, and cognitive functions of the patient.
So, again, speaking to their health values.
Do they know the patient?
How they would feel about, you know,
any kind of physical function,
how they're cognitively functioning,
what's the effect of the treatment on those things?
Maybe that best interest is going to be related
to the prognosis of the patient.
So, what are their chances of success for recovery
from the condition with or without treatment?
So, what's the natural history of the disease process?
What would the patient want knowing that?
What would the treatment do to affect that,
the prognosis of the treatment
might speak to how the surrogate
thinks about best interest.
The particular treatments might have their
own side effects or potential complications.
What's the likelihood of those things happening?
With that also speak to the best
interest of the patient, you know,
the patient would never wanna accept that complication,
so, we shouldn't go down that path.
What's the treatment going to do
for the life expectancy of the patient?
You know, how important was prolonging
the life of the patient to the patient?
Does the surrogate speak to best interest
knowing life expectancy of the patient?
Quality of life may be an important factor.
So, similar to what we're doing with patients, when we're
thinking about quantity of life versus quality of life
and trying to figure out what's important to them,
we should ask the surrogate decision maker
to think about best interests in light of
is the patient experiencing any pain, any discomfort.
Do they have dependencies that they need
to rely on a caregiver to help them with?
What are the effects of treatment on their quality of life?
Would it make it better, make it worse?
The surrogate can then say, this is how they
would think about best interest.
And then, for some patients, their religious
beliefs, their religious traditions,
their basic values may be important
to how they make medical decisions.
So, asking the surrogate, what do you know
about the patient and their religious beliefs?
That would speak to what's in their best interest in regard
to this particular medical treatment that we are proposing.