Surrogate decision-Making on Withdrawing Life-Sustaining Treatments for Critically Ill Patients

This article discusses Surrogate decision-Making on Withdrawing Life-Sustaining Treatments for Critically Ill Patients.


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Surrogate decision-Making on Withdrawing Life-Sustaining Treatments for Critically Ill Patients


Many ethical factors surround the practice of using surrogate decision-makers regarding the withdrawal of treatment for critically ill patients[HF1] . The[HF2]  ethical principles of healthcare practices stipulate that all patients have equal access to treatment. Therefore, the equality aspect means that it is unethical for individual patients to be denied treatment due to the diverse conditions they might portray. One such situation involves the treatment of critically ill patients. Individuals considered as sick critically must be given the kind of treatment they deserve for equality to hold.[HF3] 

However, the challenge stems from the need for physicians to determine what is right for the patient. Physiciansā€™ rule to seek patientsā€™ consent means that it becomes challenging to define a critically ill patientā€™s opinion. Often, critically ill patients do not have the mental capacity to make better healthcare decisions. Surrogate decision-makers, therefore, fill the void. A surrogate decision-maker refers to an individual acting as a patientā€™s representative. [HF4] The individual has the right to make healthcare decisions for patients if they lack the mental capacity to make viable choices.  The issue of surrogates making treatment decisions on behalf of patients has elicited a lot of controversies. [HF5] Arguments have been raised against the ethical nature of the practice. Understanding the role of surrogate decision-makers is attained by reviewing the practice, application to treatment withdrawal, ethical considerations for the critically ill, and challenges regarding the issue[HF6] .

Surrogate Decision Making

The entity of surrogate decision-making involves individualsā€™ use to make healthcare decisions on other peopleā€™s behalf[HF7] . The decision-making activity [HF8] is done when the patient with a surrogate does not have the mental capacity to make better choices. Different people can act as a patientā€™s surrogate. [HF9] However, the standard form of a surrogate involves an individual appointed by an attorney to make healthcare decisions on behalf of the patient (Bibas et al., 2019). The procedure for appointment of a surrogate agent involves proving oneā€™s involvement with a patient-perceived to have decision making challenges. The attorney requires that individuals demonstrate their understanding of the patientā€™s needs to be appointed as surrogates.

The process involves proof of having taken part in several health care programs involving the patient, for instance, attending counseling sessions (Butler et al. 2016)[HF10] . However, not every case of a surrogate involves agents appointed by attorneys. Close family members can also act as surrogates. The situation arises from the fact that some people may lack the mental capacity to make decisions from unfortunate events in their lives, for instance, accidents. [HF11] Therefore, the sudden turn of events means that other people have to step in and make the necessary health care decisions. It implies that surrogates have to be determined from the patientā€™s close associates. [HF12] American laws advocate for a hierarchical approach to determining surrogates. The first consideration is always given to the patientā€™s guardian. The next in line for reference is the spouse then the children and other close family members.[HF13] 

Withdrawing and Withholding Treatment

The[HF14]  decision to withdraw or withhold treatment is considered a difficult one[HF15] . Withdrawal refers to the act of removing administered healthcare treatment. [HF16] On the other hand, withholding involves putting to an end the administration of a particular treatment, for instance, ceasing to offer a specific medication upon request. Both withdrawal and withholding have the same medical consequences. The problematic nature of making the treatment withdrawal and withholding decision stems from fear of detrimental effects on the patient. The situation, therefore, leaves the patient as the one with the responsibility of deciding on the ideal treatment[HF17] .  A patient has the right to accept or reject a particular treatment despite the act promising to bring adverse health effects. The surrogate, therefore, makes treatment decisions for critically ill patients. The surrogate can decide not to initiate or withdraw a particular treatment (Wendler, 2017). The action does not attract any form of judgement as it is considered legal. For instance, after the withdrawal of treatment, a patientā€™s death does not amount to any wrongdoing as the surrogate acted within the ethical jurisdictions of their role. Therefore, the surrogate has the right to order physicians to withdraw or withhold a particular treatment for their critically ill patients (Cai et al. 2015).[HF18] [HF19] [HF20] 

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Ethical Considerations in Surrogate Withdrawal of Treatment for the Critically Ill

It is the ethical role for surrogate decision-makers to prescribe treatments [HF21] that align with the goals, values and preferences of the patients they represent. Ethical healthcare requires that patients are treated using criteria they consider suitable for their health. Patients have the right to choose the correct remedy that appeals to them from a set of alternatives. Likewise, the treatment selected should be in line with the values and beliefs of the patient. The need to observe patientsā€™ values stem from the fact that society comprises people from different communities with cultural diversities and beliefs. Some patients tend to avoid treatments that they consider to violate their cultural beliefs.

Therefore, treatment options that give preference to patientā€™s values must be considered for them to recover well. However, getting the goals, values and treatment procedures for critically ill patients may be challenging. The fact that the patients cannot choose a treatment option that they view as good in terms of values and preference makes them vulnerable to the use of wrong remedies. It is the ethical duty of surrogate to ensure that the critically illā€™s treatment values and priorities are not violated (Geros-Willfond et al. 2016). The surrogate knows the diverse aspects of the patientā€™s values and treatment. Information on patientsā€™ cultural values and treatment preferences is conveyed to the physicians by the surrogate. Therefore, the surrogate has the moral authority to withdraw treatment if it violates the patientā€™s values and preferences. Surrogates are guided by the belief that the individuals would not have accepted the treatments if they could choose.

Surrogates are tasked with liaising with the physicians to evaluate the effectiveness of the administered treatments. [HF22] The fundamental goal of any treatment intervention is to improve the patientā€™s health. One of the key avenues to identify improvement from treatment is by providing details on how they feel. Therefore, the criteria become challenging for both healthcare practitioners and the patientsā€™ loved ones in critically ill patients’ care. Difficulties in the patient relaying recovery progress make it challenging to determine the effectiveness of the given interventions. Surrogates, therefore, have the[HF23]  ethical responsibility of deciding if the treatment is responsive. A personā€™s responsiveness to treatment is determined by diverse approaches, for instance, routine monitoring of the patient to figure out any sign of improvement. However, the critical process entails constant communication with the physicians regarding the patientā€™s progress (White et al. 2016). The surrogate has the power to determine the next course of treatment intervention upon learning of the effectiveness of the current one.

The undertaken decision ought to be in line with what the patients would have preferred as ideal should they have had the right mental capacity. A decision may be made to withdraw the existing treatment if it is proven unresponsive. Often, some healthcare practitioners may oppose the decision due to its significance in the patientā€™s survival. However, the patientā€™s determined unresponsive to the treatment gives the surrogate the power to withdraw it. Likewise, the surrogate may suggest the change to other treatment options depending on their communication with physicians. Moreover, the surrogate may decide to withhold treatment for the critically ill due to unresponsiveness by calling for its discontinuation. Therefore, it is evident that surrogate decision-makers have an ethical mandate to evaluate responsiveness to treatment by the critically sick and make decisions that would have been considered viable by the patients.

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Additionally, the surrogateā€™s ethical role relies on personal judgment on what is the best decision to take. A patientā€™s health may deteriorate to levels that shutter away any glimpse of hope regarding his or her recovery. Often, physicians are aware of patients who are not likely to recover due to the severity of their conditions. The worst results may be portrayed by projections of the patientsā€™ death regardless of the administered treatments. Despite knowing patientsā€™ probable situation, physicians cannot decide on halting the treatment as doing so amounts to a violation of their professional duties. The decision to select the next course of action is therefore left to surrogates. Besides the patientā€™s values and preference, surrogates are forced to rely on their judgement on what is best.

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Surrogate decision-making on withdrawing life-sustaining treatments for critically ill patients
Surrogate decision-making on withdrawing life-sustaining treatments for critically ill patients

The decision should focus not only on the patientā€™s interest alone but also on the loved ones and the general population. Patientsā€™ interest is illustrated by thoughts of decisions they are perceived as likely to undertake should they be aware of their situation (Moss et al. 2019). Decision-making also considers the challenges experienced by patientsā€™ loved ones, for instance, the emotional and economic hurdles. Similarly, the plight of other people who may require the same treatment resources and have high probabilities of recovering is evaluated. The surrogate weighs the viability of the different options to select the one they judge to be the best for all the parties with the patientā€™s needs being central. The judgement factors in aspects such as the likelihood of the patient recovering and whether the cost being used in the treatment will result in any health benefits.

Surrogate agents may decide to withdraw or withhold treatment when they believe that it is good to relieve the patients of the struggles and let them die slowly if the physicians reveal the lack of recovery chances. The decision might also be informed by the desire to avoid excess medical costs and the emotional torture the patientsā€™ families are undergoing despite being unable to recover.

Issues on the use of Surrogate Decision-Makers

The topic of surrogate decision-making is marred with a lot of controversies. The mandate to make vital decisions on other peopleā€™s behalf has attracted a lot of questions. One such issue pertains to the viability of the decisions made. Surrogates are required to make decisions that are considered of best interest to the patients. However, the practical application of their choices may not reflect the patientsā€™ best interest. Diverse studies have established that surrogates often make a poor judgment when determining what is right for their patients. The surrogates are often not accurate in describing the patientsā€™ wishes. According to Fetherstonhaugh et al. (2017), surrogatesā€™ substituted judgment approach may not reflect the actual choice for a patient. The findings were established in a study investigating the effectiveness of surrogate decision-making among patients with dementia. The researchers recommended that healthcare workers should take an active role in helping surrogates make viable decisions on the patientā€™s behalf (Fetherstonhaugh et al. 2017). However, positive scores regarding surrogate decisions are realized if patients had suggested in advance a particular treatment preference.

Also, a lot of concerns have been raised regarding the cost of surrogate decision-making. The concerns revolve around the surrogatesā€™ safety. A 2008 study conducted by Siegel et al. established that surrogates are exposed to diverse psychological challenges. Nobody wants to be the individual who decides to end a loved oneā€™s life by ordering treatment withdrawal. Therefore, surrogates carry a lot of burden by making decisions that determine the like hood of person to live (Miller et al. 2016). The mental challenges are depicted by conditions that include panic, anxiety, depression and post-traumatic disorders. Depression and post-traumatic disorders often arise from the guilt a surrogate may have regarding their decision causing the death of the loved one (Siegel et al. 2008).

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To summarize, the issue of surrogate decision-makers and their role in withdrawing treatment for the critically ill has been evaluated. Surrogates have been described as individuals given the task to make medical decisions on behalf of patients. The need has been depicted to emerge from the lack of mental capacity for patients. Various procedures have been highlighted about the appointment of surrogates for patients. Also, withdrawal has been illustrated as the act of stopping the administration of a particular treatment. Surrogates have the right to order the withdrawal of treatment for critically ill patients.

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Surrogate decision-making on withdrawing life-sustaining treatments for critically ill patients
Surrogate decision-making on withdrawing life-sustaining treatments for critically ill patients

Diverse ethical considerations have been portrayed to influence surrogateā€™s actions. The surrogatesā€™ decisions rely on the patientā€™s values, the progress of treatment and personal judgement. Likewise, the diverse issue pertaining to the practice of surrogate decision-makers have been evaluated. Inefficiencies have been depicted in situations where the surrogatesā€™ decisions may not reflect the patientā€™s real stand. Also, surrogates have been described as experiencing diverse psychological effects. Nevertheless, the use of surrogates in the treatment of the critically ill is ethical, provided that the decisions made reflect the patientsā€™ interest. The approach ensures equality in treatment for all citizens.


Bibas, L., Peretz-Larochelle, M., Adhikari, N. K., Goldfarb, M. J., Luk, A., Englesakis, M., … & Lawler, P. R. (2019). Association of surrogate decision-making interventions for critically ill adults with patient, family, and resource use outcomes: a systematic review and meta-analysis. JAMA network open, 2(7), e197229-e197229.

Butler, J. M., Hirshberg, E. L., Hopkins, R. O., Wilson, E. L., Orme, J. F., Beesley, S. J., … & Brown, S. M. (2016). Preliminary identification of coping profiles relevant to surrogate decision making in the ICU. PloS one, 11(11), e0166542.

Cai, X., Robinson, J., Muehlschlegel, S., White, D. B., Holloway, R. G., Sheth, K. N., … & Hwang, D. Y. (2015). Patient preferences and surrogate decision making in neuroscience intensive care units. Neurocritical care, 23(1), 131-141.

Fetherstonhaugh, D., McAuliffe, L., Bauer, M., & Shanley, C. (2017). Decision-making on behalf of people living with dementia: how do surrogate decision-makers decide?. Journal of Medical Ethics, 43(1), 35-40.

Geros-Willfond, K. N., Ivy, S. S., Montz, K., Bohan, S. E., & Torke, A. M. (2016). Religion and spirituality in surrogate decision making for hospitalized older adults. Journal of religion and health, 55(3), 765-777.

Miller, J. J., Morris, P., Files, D. C., Gower, E., & Young, M. (2016). Decision conflict and regret among surrogate decision-makers in the medical intensive care unit. Journal of critical care, 32, 79-84.

Moss, K. O., Douglas, S. L., Baum, E., & Daly, B. (2019). Family surrogate decision-making in chronic critical illness: a qualitative analysis. Critical care nurse, 39(3), e18-e26.

Siegel, M. D., Hayes, E., Vanderwerker, L. C., Loseth, D. B., & Prigerson, H. G. (2008). Psychiatric illness in the next of kin of patients who die in the intensive care unit. Critical care medicine, 36(6), 1722-1728.

Wendler, D. (2017). The Theory and Practice of Surrogate Decisionā€Making. Hastings Center Report, 47(1), 29-31.

White, D. B., Ernecoff, N., Buddadhumaruk, P., Hong, S., Weissfeld, L., Curtis, J. R., … & Lo, B. (2016). Prevalence of and factors related to discordance about prognosis between physicians and surrogate decision-makers of critically ill patients. Jama, 315(19), 2086-2094.

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