Surrogate medical decision makers generally fall into one of two archetypes: the “preferences advocate," who channels the patient's values, and the “clinical facilitator," who bases decisions on the patient's clinical status. These classifications were developed by authors of a survey, the findings of which were published in the August 2017 issue of Surgery. However, the authors note that knowledge of clinical practice or the patient's preferences alone did not dictate that the surrogate would fall into either category. For examples of the two types of decision makers, a preference advocate was quoted as saying: “It means making the decision that my father wants, ultimately. Not what I want or anyone in my family wants," while a clinical facilitator was quoted as saying: “I did a little bit of research and found that you can live with half your small intestine, and it's not clear how many feet you have, but the minimum that I've seen was 11 feet. . . and she only lost three feet, so she should be able to get to 100% recovery." Preference advocates framed the treatments chosen as “consistent with the patient's values," while clinical facilitators would make treatment decisions that “directly contradicted" the patient's preferences because the treatments were perceived to be in the patient's best interest. The authors note that, although surrogate decision making is the standard, it may hinder treatment that adheres to the patient's preferences. Specifically, they say, clinical facilitators are more likely to overrule the patient's values if they perceive benefit to treatment. The authors recommend that “clarification of the surrogate role and more explicit delineation of priorities and values" may help surrogate decision makers uphold the ethical obligations of their responsibility.

HRC Recommends: Organizations should review how they educate, work with, and support family members and other caregivers of patients who may become the patient's surrogate decision maker, to ensure that surrogate candidates understand their ethical responsibilities and how these duties should be fulfilled. The organization should also review state statutes regarding eligibility of surrogate decision makers, as well as ensure that these requirements are reflected in organization policy.