HEC Forum

pp 1–16 | Cite as

Making Medical Decisions for Incapacitated Patients Without Proxies: Part II

  • Eric BlackstoneEmail author
  • Barbara J. Daly
  • Cynthia Griggins


In the United States, there is no consensus about who should make decisions in acute but non-emergent situations for incapacitated patients who lack surrogates. For more than a decade, our academic medical center has utilized community volunteers from the hospital ethics committee to engage in shared decision-making with the medical providers for these patients. In order to add a different point of view and minimize conflict of interest, the volunteers are non-clinicians who are not employed by the hospital. Using case examples and interviews with the community members, this paper describes how the protocol has translated into practice over the years since its inception. Members reported comfort with the role as well as satisfaction with the thoroughness of their discussions with the medical team. They acknowledged feelings of moral uncertainty, but expressed confidence in the process. Questions raised by the experience are discussed. Overall, the protocol has provided oversight, transparency, and protection from conflict of interest to the decision-making process for this vulnerable patient population.


Unbefriended Unrepresented Surrogate decision-making Substituted judgment Ethics committees 



Olubukunola Dwyer and Lauren McAliley for assisting with the interviews, and the PWP committee volunteers.

Compliance with Ethical Standards

Conflict of interest

The authors have no conflict of interest to disclose.


  1. Courtwright, A. M., Abrams, J., & Robinson, E. M. (2017). The role of a hospital ethics consultation service in decision-making for unrepresented patients. Journal of Bioethical Inquiry, 14(2), 241–250.CrossRefGoogle Scholar
  2. Courtwright, A., & Rubin, E. (2015). Who should decide for the unrepresented? Bioethics, 30(3), 173–180.CrossRefGoogle Scholar
  3. Ditto, P. H., Danks, J. H., Smucker, W. D., Bookwala, J., Coppola, K. M., Dresser, R., et al. (2001). Advance directives as acts of communication: A randomized controlled trial. Archives of Internal Medicine, 161(3), 421–430.CrossRefGoogle Scholar
  4. Elwyn, G., Frosch, D., Thomson, R., Joseph-Williams, N., Lloyd, A., Kinnersley, P., et al. (2012). Shared decision making: A model for clinical practice. Journal of General Internal Medicine, 27(10), 1361–1367.CrossRefGoogle Scholar
  5. Fagerlin, A., Ditto, P. H., Danks, J. H., Houts, R. M., & Smucker, W. D. (2001). Projection in surrogate decisions about life-sustaining medical treatments. Health Psychology, 20(3), 166–175.CrossRefGoogle Scholar
  6. Griggins, C., Blackstone, E., McAliley, L. et al. (2019). Making medical decisions for incapacitated patients without proxies: Part I. HEC Forum. Scholar
  7. Hyun, I., Griggins, C., Weiss, M., Robbins, D., Robichaud, A., & Daly, B. (2006). When patients do not have a proxy: A procedure for medical decision making when there is no one to speak for the patient. Journal of Clinical Ethics, 17(4), 323–330.Google Scholar
  8. Janis, I. L. (1972). Victims of groupthink. Boston: Houghton Mifflin.Google Scholar
  9. Kim, H., & Song, M. (2018). Medical decision-making for adults who lack decision-making capacity and a surrogate: State of the science. American Journal of Hospice and Palliative Medicine, 35(9), 1227–1234.CrossRefGoogle Scholar
  10. Pope, T. M. (2017). Unbefriended and unrepresented: Better medical decision making for incapacitated patients without healthcare surrogates. Georgia State University Law Review, 33(4), 923–1019.Google Scholar
  11. Prang, K. H., Berecki-Gisolf, J., & Newnam, S. (2015). Recovery from musculoskeletal injury: The role of social support following a transport accident. Health and Quality of Life Outcomes, 13, 97.CrossRefGoogle Scholar
  12. Robichaud, A. L. (2015). Medical decision making for patients without proxies: The effect of personal experience in the deliberative process. Journal of Clinical Ethics, 26(4), 355–360.Google Scholar
  13. Sequeira, A., & Lewis, A. (2017). Ethical and legal considerations in the management of an unbefriended patient in a vegetative state. Neurocritical Care, 27(2), 173–179.CrossRefGoogle Scholar
  14. Treen, E., Atanasova, C., Pitt, L., & Johnson, M. (2016). Evidence from a large sample on the effects of group size and decision-making time on performance in a marketing simulation game. Journal of Marketing Education, 38(2), 130–137.CrossRefGoogle Scholar
  15. White, D. B., Curtis, J. R., Lo, B., & Luce, J. M. (2006). Decisions to limit life-sustaining treatment for critically ill patients who lack both decision-making capacity and surrogate decision-makers. Critical Care Medicine, 34(8), 2053–2059.CrossRefGoogle Scholar
  16. White, D. B., Curtis, J. R., Wolf, L. E., Prendergast, T. J., Taichman, D. B., Kuniyoshi, G., et al. (2007). Life support for patients without a surrogate decision maker: Who decides? Annals of Internal Medicine, 147(1), 34–40.CrossRefGoogle Scholar
  17. White, D. B., Johnsen, A., & Lo, B. (2012). Ethical challenge: When clinicians act as surrogates for unrepresented patients. American Journal of Critical Care, 21(3), 202–207.CrossRefGoogle Scholar

Copyright information

© Springer Nature B.V. 2019

Authors and Affiliations

  1. 1.Frances Payne Bolton School of NursingCase Western Reserve UniversityClevelandUSA
  2. 2.Case Western Reserve UniversityClevelandUSA
  3. 3.Department of Neurology, Neurological Institute, University Hospitals Cleveland Medical CenterCase Western Reserve University School of MedicineClevelandUSA

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