• Alexandre Lautrette, Vincent Peigne, Jeffrey Watts, Bertrand Souweine, and Elie Azoulay.
• Services de Réanimation Médicale, Hôpital Saint-Louis, Paris, France.
• Curr Opin Crit Care. 2008 Dec 1;14(6):714-9.

Purpose Of ReviewFrequently, ICU patients lack the capacity to share discussions and make decisions about their health. Designation of a surrogate and advance directives have been proposed to empower patients and give more place to their autonomy. Even though legitimacy of surrogates is now recognized by physicians, patients' management must take into account new legislations emphasizing patients' autonomy all over Europe.Recent FindingsOver the last decade, most western European countries have recognized the validity of advance directives and the process of substitute decision making when a patient is incapacitated. Although the laws of these countries reflect the same approach, there are several differences in the mode of designation of surrogates and in their decisional authority.SummaryThe present review compares the legal framework of surrogacy in Belgium, Denmark, England, France, Germany, the Netherlands, Spain, and Switzerland. France is the country that confers the weakest power to surrogates in decision making. Patients' competence and the ability of surrogate decision makers to cope with ICU's burden are discussed as the main limitations of the substitute decision-making process. Measures to improve substitute decision making and to limit harmful repercussions are suggested.

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