Who has the highest priority to make decisions for a patient lacking capacity when there is no advance directive?

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When someone cannot make their own health care decisions, the person who should decide is the designated surrogate decision-maker—the individual the patient chose to represent them in medical choices. This designation is made while the patient is still able to express preferences and is meant to reflect what the patient would want. Even if there isn’t a formal advance directive, having a designated surrogate provides a clear authority to guide treatment decisions, ensuring choices align with the patient’s values. This surrogate’s role overrides default assumptions about who should decide (like a spouse or the oldest relative) and is distinct from the physician’s role, which is to inform and carry out medically appropriate options rather than determine decisions himself or herself. If no designated surrogate exists, decisions would then follow a legal hierarchy or a guardian appointment, but when a designated surrogate is in place, they hold the highest priority to represent the patient’s wishes.