Health Care Providers

Substitute Decision-Makers: End-of-Life Decision-Making when the Patient is Incapable

When a person is incapable, they risk losing their dignity and respect for their intrinsic value as persons since their beliefs, goals and culture may not be honored.

Written advance directives and the appointment of substitute decision-makers are attempts to ensure that, when incapable, a person is still able to express their goals, choose treatments to reflect the things that matter to them.

  • If a person is not capable of making health care decisions, physicians must involve their appointed substitute decision-maker or the government office of Public Guardian and Trustee.
  • Unless a substitute decision-maker is appointed in a Durable Power of Attorney for Health Care Decisions, most provincial legislation details who the physician may turn to as substitute decision-maker. In this legislation, the order of people who may act as substitute decision-maker is:
    1. the patient's spouse or partner
    2. his/her child(ren)
    3. his/her parent(s)
    4. his/her sibling(s)
    5. other relatives 
  • Once appointed, the substitute decision-maker has the authority over all other family members with respect to making decisions for the incapable person.
  • Substitute decision-makers are asked to decide not what treatments they personally would want in the patient's situation but what the patient would have wanted if he/she was still able to tell the health care team.
  • If the patient's wishes are not known or cannot be predicted, decisions can be made according to what substitute decision-makers and the health care team feel to be in the patient's best interests.
  • When the family acts as substitute decision-makers, they experience the same emotions as families do when the patient is competent.¬† However, as surrogates, they are under additional pressure to understand the severity of illness, the treatment options and to make the "best decision".¬†

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