How should consent be handled when the patient lacks decisional capacity and a surrogate decision-maker is involved?

• A. Surrogate decisions should be made solely by the physician
• B. The surrogate determines all care without patient values
• C. The surrogate's authority must be verified and decisions should align with patient preferences and best interests, with documentation
• D. Surrogate involvement is not permitted

Answer: (C)

When a patient lacks decisional capacity, the responsible approach is to recognize that someone else may guide decisions, but their authority must be verified and the choices they make should reflect what the patient would want and what is in the patient’s best interests. This means confirming who has legal authority to consent—such as a documented health care proxy, durable power of attorney for health care, or a court-appointed guardian—and ensuring that this authority is legitimate and active before acting.

Once authority is confirmed, decisions should be grounded in the patient’s known preferences. If the patient previously expressed specific wishes about treatments, those substituted judgments should guide care. If those preferences aren’t known, decisions should be based on the patient’s best interests, considering factors like quality of life, burdens and benefits of treatments, and the patient’s values, beliefs, and cultural or religious considerations. Throughout, clinicians should document the surrogate’s designation, the rationale for decisions, the discussions held, and the consent given, with clear notes on time, date, and any uncertainties. This documentation supports ethical practice and legal accountability and allows for re-evaluation if the patient’s capacity returns.