What to do when patients lack decision-making capacity, surrogates


Health professionals frequently care for patients who are unrepresented—those who lack decision-making capacity, identifiable surrogates, and advance directives.

Unrepresented patients are often homeless, disabled, elderly or incarcerated, and are among the most vulnerable. When treating unrepresented patients, how should physicians and health care teams respond to their needs?

The July issue of the AMA Journal of Ethics® (@JournalofEthics) features numerous perspectives on the ethics of representing unrepresented patients and gives you an opportunity to earn CME credit.

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Articles include:

How Should Clinicians Navigate Decision Making for Unrepresented Patients?” A deliberative approach to responding to needs and vulnerabilities of unrepresented patients can help make the most of having too little information.

Five Things Clinicians Should Know When Caring for Unrepresented Patients.” Despite challenges of decision making for unrepresented patients, few laws or policy statements offer solutions. This article suggests five key things to do.

When There’s No One to Whom an Error Can Be Disclosed, How Should an Error Be Handled?” When a patient lacks capacity and a surrogate, alternative strategies must be implemented to document and try to rectify an error.

Who Should Make Decisions for Unrepresented Patients Who Are Incarcerated?” Decisions for patients who are unrepresented and incarcerated could be made by different classes of possible decision makers “inside” and “outside.”

In the journal’s July podcast, expert Scott J. Schweikart, a senior research associate for the AMA Council on Ethical and Judicial Affairs and legal editor for the AMA Journal of Ethics, discusses three common approaches to caring for unrepresented patients.

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David Ozar, PhD, is professor emeritus of ethics, social philosophy, and professional and health care ethics in the Department of Philosophy at Loyola University Chicago. He is also an ethics committee member and consulting ethicist for NorthShore University HealthSystem. On the podcast, Ozar explains policy challenges health professionals face when caring for unrepresented patients in emergencies.

Listen to previous episodes of the podcast, “Ethics Talk,” or subscribe in iTunes or other services.

The AMA Journal of Ethics CME module, “How Should Unaccompanied Minors in Immigration Detention Be Protected From Coercive Medical Practices?” is designated by the AMA for a maximum of 1 AMA PRA Category 1 Credit™.

The module is part of the AMA Ed Hub™, an online platform that brings together high-quality CME, maintenance of certification, and educational content—in one place—with relevant learning activities, automated credit tracking and reporting for some states and specialty boards.

Learn more about AMA CME accreditation.

The journal’s editorial focus is on commentaries and articles that offer practical advice and insights for medical students and physicians. Submit a manuscript for publication. The journal also invites original photographs, graphics, cartoons, drawings and paintings that explore the ethical dimensions of health or health care.

Ethics in Health Care

Explore the AMA Journal of Ethics for articles, podcasts and polls that focus on ethical issues that affect physicans, physicians-in-training and their patients.

The AMA Journal of Ethics Conley Art of Medicine Contest and Conley Ethics Essay Contest for medical students, residents, and fellows are now open.

The journal’s call for theme issue editors is now open. Medical students, residents and fellows in U.S.-based programs are invited to apply to serve as theme issue editors for monthly issues to be published in 2021–2022.

The August issue of the AMA Journal of Ethics will focus on access to prescription medications. Sign up to receive email alerts when new issues are published.