Sorting Through Surrogates

Similar to the previous situation, ethics consults are occasionally obtained when it's not clear to the treating team who the surrogate decision maker is or how to navigate conflicts between decision makers. In California and by our policy, a surrogate decision maker can be anyone who knows the patient and his values well enough to make decisions on his behalf. There is no predetermined hierarchy of relationship; a neighbor may be a better surrogate than an estranged spouse who hasn't seen the patient in a decade. It's not uncommon that we find ourselves in complex family and friend relationships with multiple spouses, children, cousins, friends, and parents who all want a say in medical decision making. We hope that all the stakeholders are on the same page and work together to determine what's best for a patient, but this is rare. Especially in the intensive care unit, situations can be emotionally-laden and challenging to achieve a consensus. Furthermore, it's quite important to identify a single spokeperson if possible. Having been in a lot of these situations, I find that having a point person for the medical team to communicate with who then distributions information to the rest of the family is much more effective than having too many people giving and receiving too many messages.

The ethics committee is a good tool to sort through these issues when they get complicated. We are willing to take the time, speak to all the players, navigate the conflicts, and pinpoint the relationships between all the relatives and friends with the patient. By divorcing ourselves from the treating time, we can maintain a little more objectivity in assessing the appropriate surrogate. When conflicts develop between key decision makers, we can broker that communication, almost playing the role of a counselor.