Healthcare Decision Making

An important part of bioethics analysis and clinical ethics consultation is helping patients, families and care professionals make decisions about care. 

Healthcare decisions are customarily made by adults who have the capacity and information to make choices that reflect their personal values, preferences and healthcare goals. 

Sometimes, however, a patient may not have sufficient ability to make care decisions.  Under these circumstances, decisions on the patient’s behalf must be made by others, typically an appointed healthcare agent, family or other surrogates. 

Making healthcare decisions for an incapacitated patient is less burdensome and more authentic if the surrogate knows or can interpret what the patient would have wanted in the current clinical circumstances.

Advance Directives

Advance directives are legal documents that allow capable people to express their healthcare wishes so that, if and when they are temporarily or permanently unable to make decisions because of illness or injury, their wishes can be communicated and honored.  Two types of advance directives plus a combined form are common: 

  • Appointment directives (healthcare proxy or power of attorney for healthcare) – These directives authorize the capable individual to legally appoint another person (healthcare agent) to make healthcare decisions if the individual becomes temporarily or permanently unable to do so.  An alternate agent is also appointed to assume decision-making responsibilities in the event that the agent is not available.  The healthcare proxy appointment is the preferred type of directive because it enables the agent to talk with the care team in real time, interpret the patient’s wishes, and respond to unanticipated or changing clinical conditions.
  • Instructional directives (living wills) – These directives are lists of treatments that the person would or would not want under specified circumstances, usually at the end of life.  The living will is limited to the instructions on the page, which may or may not apply to the individual’s clinical condition when decisions need to be made.
  • Combined directives – These directives combine the features of the appointment and instructional directives, authorizing the appointment of an agent and alternate, and providing for the statement of optional instructions.

The Hackensack University Medical Center advance directive booklet is available for download.The booklet includes the form to complete, appointing a healthcare agent and alternate agent; explanation and directions; and two wallet-size cards, one that has the name and contact information for the healthcare agent and alternate agent, and one for optional organ donation.

Healthcare proxy appointment 

  • A healthcare agent is a capable adult over 18 years of age who has been selected and legally appointed by the patient, and empowered to make healthcare decisions on behalf of the patient when the patient is temporarily or permanently unable to do so.
  • An agent’s decision-making authority is not limited to end-of-life situations and includes any healthcare decisions that a capable person may make.      
  • A lower level of capacity is required to appoint a healthcare agent than to make the clinical decisions that the agent will make.  For that reason, an individual who lacks the capacity to make complex treatment decisions may still be able to appoint an agent.
  • Because an agent is specifically chosen and appointed by a capable individual, a patient’s next of kin is not automatically the healthcare agent.  As a result, the person who knows the patient best may be unable to guide treatment plans if not appointed as the agent.  The decisional authority of the agent and alternate replaces that of anyone else, including next of kin.
  • If the patient’s prior instructions do not address the clinical situation at the time of decision making, the agent has the power to determine what the patient would have chosen or what is in the patient’s best interest and help guide decisions about the goals and plan of care.

Living wills 

Because a living will is a list of instructions about specific treatments that would be wanted or rejected, usually at the end of life, its provisions may not apply to the patient’s current clinical situation.

A living will is most useful as a guide to decision making for patients who have no one to appoint as a healthcare agent.

How Advance Directives Are Used 

  • The best time to complete an advance directive, especially the appointment of a healthcare agent, is when the individual is healthy, capable and able to carefully consider the appointment and instructions.  Selection of an agent should consider the responsibilities of decision making for another person, as well as the individual’s wishes and values.  The content of advance directives should be discussed with the patient’s physician, family and trusted others. 
  • Copies of advance directives should be given to the agent and alternate agent, physician and family, and should be brought to the hospital or other care-providing facility for inclusion in the medical record.
  • Federal and state law mandate that all care-providing facilities ask patients on admission whether they have an advance directive and, if so, to ensure that a copy is in the medical record to guide decisions.  If the patient does not have an advance directive, the facility must offer information and assistance in completing a directive if patients wish to do so.  At HackensackUMC, the Consumer Affairs Department (551-996-2010) is available to assist in completing advance directives.
  • The provisions of an advance directive, including the powers of the healthcare agent, are activated only when:
    • the patient has been determined to have temporarily or permanently lost decisional capacity, and
    • in the case of a living will, the patient is in the clinical condition(s) specified in the directive. 
  • If and when the patient regains decisional capacity, he or she resumes making healthcare decisions.
  • Advance directives can be changed at any time and the most recent directive replaces all prior directives.  If a patient is admitted to a care-providing facility without a previously completed advance directive, a new directive can be completed, which will replace previous directives.

At HackensackUMC, patients will be asked about advance directives 

  • upon admission (either through the Admissions Department or through the Emergency Trauma Department),
  • during nursing assessment, and
  • during the initial discussion with the admitting physician. 

In addition, patients will be reminded by the Scheduling Department to bring their advance directives when they come for elective admissions.  Advance directives will be scanned into the institution’s electronic information system so that they can be retrieved and referred to on subsequent admissions.

An informal surrogate is a capable adult over 18 years of age who, although not specifically chosen or legally appointed, assumes responsibility for making healthcare decisions on behalf of a patient who has lost capacity and does not have an advance directive.  Typically, family members, specifically next of kin, assume this responsibility.  The decision-making authority of informal surrogates differs according to the state in which the patient is receiving care.

The Clinical Ethics Consultation Service (551-996-4179) is available to meet with patients, families and the care team to address and resolve uncertainties and conflicts related to the interpretation and implementation of advance directives.

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