When a patient cannot make decisions, whose determinations should guide ethical decisions, and what should they reflect?

• A. The physician alone decides.
• B. The nurse makes the final call.
• C. The surrogate's determinations should reflect the patient’s values and prognosis.
• D. Hospital policy overrides patient values.

Answer: (C)

When a patient cannot participate in decisions, a surrogate decision-maker steps in to guide care. This person is typically a legally designated health care proxy or a close family member who knows the patient’s values. The determinations they make should reflect what the patient would have wanted, taking into account the patient’s values about quality of life and acceptable burdens, as well as the likely prognosis and outcomes of available treatments. This is the substituted judgment approach; if the patient’s preferences aren’t known, the surrogate should decide in the patient’s best interests, aiming to relieve suffering and maximize benefit. The goal is to align care with the patient’s goals rather than with what any clinician or the hospital policy alone might prefer. If there’s uncertainty or disagreement, the care team can help clarify values and, if needed, involve an ethics consultation.