In surrogate decision-making when wishes are unknown, which standard guides decisions?

• A. Substituted judgment
• B. The clinician's judgment alone
• C. Best interests
• D. The patient's family’s preferences

Answer: (C)

When a patient can’t participate in decisions and there are no known wishes, the standard used to guide surrogate decisions is what would be in the patient’s best interests. This means weighing the likely benefits and burdens of possible treatments to determine what would promote the patient’s overall welfare, comfort, dignity, and reasonable quality of life given their prognosis. The focus is on reducing suffering and avoiding treatments that cause more harm than benefit, while considering any values the patient demonstrated in the past or through family input.

Substituted judgment is used when there are clear prior wishes or an advance directive and you try to reproduce the patient’s own choice. Relying on the clinician’s judgment alone or on family preferences without anchoring to the patient’s best interests can lead to decisions that don’t align with the patient’s welfare, especially when the patient’s own preferences are unknown. If there are known values from the patient, those can help inform the best-interests assessment, but the ultimate standard in the unknown-wishes scenario is what would most benefit the patient’s well-being.