When a patient lacks sufficient capacity to make a decision about his/her medical care, someone else must make that decision. This individual is designated as the patient's surrogate decision-maker, guardian, or designated proxy for health care decisions. The latter two terms are legal terms. For the rest of this document, I'll simply use the term surrogate to refer to the person who makes health care decisions for the patient.

Being a patient surrogate is a heavy responsibility. One has to make difficult decisions that will have a major impact on the patient's life. Therefore, there are standards for surrogate decision-making. These help guide the surrogate. They also provide a basis for others to evaluate the surrogate's decision in order to protect the patient from irresponsible or unethical surrogates.

STANDARDS: There are three main standards used for surrogate decision-making. They are in order from most preferred to least.

1. Expressed Interests Standard - This standard refers all health care decisions to explicit instructions that the patient provided prior to losing his/her decision-making capacity. Under this standard, the surrogate makes care decisions in accordance with the patient's advance directive or prior statement.

2. Substituted Judgement - Under this standard, the surrogate refers to the patient's values, beliefs, character traits, and past decisions in order to make an educated guess with regard to what the patient would have decided in this particular instance. Essentially, you are trying to use the patient's own standards to make the decision, however, you do not have an advance directive or the advance directive does not cover the situation at hand.

3. Best Interests Standard - This standard is used when you have no indication of what the patient's values are or what he/she would have wanted. Therefore, you use your own judgement. You decide what is in the patient's best interests.