Authority needs to be established
A surrogate makes health care decisions for someone who cannot make the relevant decision themselves, within the authority provided by law or an applicable designation. A named health care agent, a court-appointed representative and a relative identified through a statutory process are not interchangeable categories.
The National Institute on Aging explains the role of a chosen health care proxy and emphasizes state-specific forms and requirements. The AMA’s physician ethics guidance directs clinicians to identify an appropriate surrogate through the patient’s designation or applicable law and policy. Neither source establishes one nationwide family hierarchy.
Verify the basis for involvement
When another person is asked to decide, help the team establish who they are, how they obtained authority and how to contact them. Locate relevant documents through the approved record process. Ask the responsible team to resolve incomplete or conflicting information.
Do not assume that being an emergency contact, visiting most often or describing oneself as “next of kin” answers the authority question. Likewise, a document concerning finances should not be treated as sufficient health care authority without review.
Suggested handoff questions include:
- What decision is currently needed?
- What capacity assessment or other process supports involving a surrogate?
- Who has been identified and on what basis?
- Are there limits or unresolved questions about that authority?
- What has the patient previously said about this decision or related values?
Support the patient’s perspective
AMA ethics guidance distinguishes substituted judgment, which draws on the patient’s known preferences and values, from a best-interest approach when those preferences cannot reasonably be determined. It also advises continued patient participation to the extent possible.
In a fictional family meeting, a relative says, “I would choose this for myself.” A helpful follow-up is, “What do you think matters most to the patient, based on what they have told you?” The question invites the surrogate to represent the patient rather than be judged for facing a difficult choice.
Offer clear routes for additional explanations. The surrogate may need time with the responsible clinician to understand the options and their implications. Nursing observations about the patient’s expressed priorities can contribute without replacing that discussion.
Address disagreement through the right process
When authority is disputed or treatment disagreement remains unresolved, involve the designated ethics or institutional resource. Do not select a decision maker simply because that person agrees with the team.
Document relevant conversations and outstanding questions in the approved record. NIA recommends keeping proxy contact information and planning documents available and updated; check that the receiving team can find them during transitions.
See advance directives for document handling and ethics consultation for a structured way to discuss unresolved values or authority concerns.
Sources
- National Institute on Aging: Choosing a Health Care Proxy (accessed 2026-09-17).
- AMA Code of Medical Ethics: Decisions for Adult Patients Who Lack Capacity (accessed 2026-09-17).