Clinics in geriatric medicine
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Clin. Geriatr. Med. · Aug 1994
ReviewSurrogate decision making. Who will make decisions for me when I can't?
The necessity of surrogate decision making arises for geriatric patients who can no longer make decisions for themselves. Almost every clinical situation involves some assessment of a patient's decisional capacity. Because decisional capacity is decision specific and entails the ability to manipulate information, it is best to conduct functional evaluations and use psychiatric measurements for dementia cautiously in determining decisional capacity. ⋯ These theoretical grounds are supplemented by emerging empirical evidence that elderly patients themselves almost always prefer that family members serve in the role of surrogate decision makers. Dealing with family surrogates obliges the geriatrician to ensure that failures in communication do not arise and that conflicts of interest are avoided in protecting the best interests of the patient. Although recent legal climate has shown a preference for a substituted judgment standard in surrogate decision making, medical concern for the best interests of the patient, together with empirical evidence that the elderly are most interested in decisions that arise out of trusted interdependencies, suggests that rules and laws are no substitute for the good faith human actions of trusted surrogates.
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One important device that has evolved within the legal system for dealing with the problem of cognitively incapacitated individuals and the concomitant need for some form of surrogate decision making on their behalf is guardianship. This article outlines the most salient ethical challenges related to guardianship for clinicians who interact professionally with older persons of diminished capacity and their families. Special attention is devoted to the clinician's role in initiating guardianships, questioning the guardian, in the guardianship proceeding, and evaluating the therapeutic impact of guardianship.