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Ideas and Opinions |

Surrogate Decision Making: Reconciling Ethical Theory and Clinical Practice

Jeffrey T. Berger, MD; Evan G. DeRenzo, PhD; and Jack Schwartz, JD
[+] Article and Author Information

From School of Medicine, State University of New York at Stony Brook, Stony Brook, New York; Washington Hospital Center, Washington, DC; and the Office of the Attorney General of Maryland, Baltimore, Maryland.


Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Jeffrey T. Berger, MD, 222 Station Plaza North, Suite 518, Mineola, NY 11501; e-mail, jberger@winthrop.org.

Current Author Addresses: Dr. Berger: 222 Station Plaza North, Suite 518, Mineola, NY 11501.

Dr. DeRenzo: 4 Grovepoint Court, Rockville, MD 20854.

Mr. Schwartz: 12203 Linden Linthicum Lane, Clarksville, MD 21029.


Ann Intern Med. 2008;149(1):48-53. doi:10.7326/0003-4819-149-1-200807010-00010
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The care of adult patients without decision-making abilities is a routine part of medical practice. Decisions for these patients are typically made by surrogates according to a process governed by a hierarchy of 3 distinct decision-making standards: patients' known wishes, substituted judgments, and best interests. Although this framework offers some guidance, it does not readily incorporate many important considerations of patients and families and does not account for the ways in which many patients and surrogates prefer to make decisions. In this article, the authors review the research on surrogate decision making, compare it with normative standards, and offer ways in which the 2 can be reconciled for the patient's benefit.

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In Response
Posted on July 16, 2008
Michael I. Weintraub
New York Medical College
Conflict of Interest: None Declared

The following letter is regarding the recent article by Berger and colleagues regarding surrogate decision making: "Reconciling Ethical Theory and Clinical Practice." I believe my comments dramatize the dilemma faced by selective physician groups.

The recent article by Berger and co-workers (1) regarding surrogate decision making was most informative yet the short-comings and ethical challenges of this process disproportionately impact the neurological and emergency medicine communities in routine treatment of subjects with acute ischemic stroke. Despite the success of the 1995 National Institute of Neurological Disorders and Stroke (NINDS) using intravenous recombinant tPA within three hours for acute ischemic stroke and its subsequent FDA approval, there has been a reluctance to use tPA because of safety and efficacy issues. (2) Given the limited window of opportunity to timely administer tPA within three hours "time is brain" and the fact that many patients are neurologically challenged and unable to comprehend the complex issues, several scenarios have been described. In one reported study,(3) 16% of stroke patients received treatment with tPA but had no documented informed consent whereas surrogates provided informed consent (63%) despite patients having competence (testamentary capacity). Additionally, patients with diminished capacity sometimes provided their own consent (18%).

In stroke research, the requirement for written informed consent to participate in the Canadian Stroke Registry was felt to be impractical (4) with only 39% participating. The authors felt that this led to important selection biases that registry patients were not representative of the typical patients with stroke.

It would appear that the informed consent process and dependence upon surrogates is inconsistent.

REFERENCES:

1. Berger JD, DeRenzo EG, Schwartz J: Surrogate decision making: Reconciling ethical theory and clinical practice. Ann Intern Med 2008; 149: 48-53.

2. Weintraub MI: Thrombolysis (Tissue plasminogen activator in stroke: A medicolegal quagmire. Stroke 2006; 37: 1917-1922.

3. Rosenbaum JR, Bravata DM, Concato J, et al: Informed consent for thrombolytic therapy for patients with acute ischemic stroke treated in routine clinical practice. Stroke 2004; 35: e353-e355.

4. Tu JV, Willison DJ, Silver FL, et al: Impracticability of informed consent in the Registry of the Canadian Stroke Network. N Eng J Med 2004; 350: 1414-1421.

Conflict of Interest:

None declared

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