Engaging The Patient

Featured Guest Blogger:  Monica Williams-Murphy, MD

Monica Williams-Murphy, MD

This is the task of surrogate medical decision-making

What if you received a phone call at 3:00am, awakening you from a deep sleep to hear my voice on the line, “I’m so sorry to wake you, but your mother (or father/spouse/etc.) is under my care here in the Emergency Department.  She’s in critical condition and appears to have had a massive stroke; she is basically unconscious. I know this is tough to hear, but she doesn’t appear to have any advance directives. And I’ve come to the point where we must decide whether or not to put her on life support. As her closest relative, I have to ask you….”

These are words that no one ever wants to hear, but it is quite possible that you will be asked to participate in such a decision for a loved one at some point in your own life. If you consider yourself to be health literate, you might feel more competent in helping to make such a decision, especially if your loved one had previously created and shared an advance directive with you.

But, what if your loved one had never written or discussed personal preferences or wishes regarding critical and end-of-life medical care?  How do we make decisions for others when they are unable to make decisions for themselves?

This is one of the challenges of surrogate medical decision-making, meaning you, as the health care proxy [by selection or default (as in my story)], must guide the choices regarding which medical interventions will be chosen or declined for your loved one.

So, how would you make such a critical decision without guidance?  

Well, our natural inclination is to choose what we want for our loved one. But, this is not the correct orientation for making a surrogate decision. When we’re making a decision for another, one who has lost decision-making capacity, we should focus on what he or she would desire for himself or herself given the situation.

As the doctor, I should never pose the following question:

“As her closest relative, I have to ask you what you want me to do next…”

Instead, I should ask:

“As her closest relative, I have to ask you what you think your mother would want me to do next…”

So, now you are asking yourself, “How would I be able to know what mother would want if she had never told me?”

This is a great question.

In response, I have created a tool to help you answer questions such as these, from the perspective of what your loved one would want.  I call this tool The 4 R’s.

The Four R’s: A Tool for Surrogate Medical Decision-Making

(click here to download a print-friendly version)

You, as the surrogate medical decision-maker, do not have to decide what to do by yourself. Let (your loved one) decide for himself or herself, following these four steps:

1. Reflect
Think back and imagine (your loved one) when he or she was still able to make his or her own decisions.

2. Reconstruct preferences
Answer the following questions: What are his or her favorite things? What is his or her favorite color? What are his or her hobbies? What is his or her favorite meal? What things did he or she dislike?

3. Reconstruct values
Think about whom he or she was, his or her opinions, his or her beliefs. What were his or her values? How did he or she choose to live his or her life?

4. Review medical options and decide
Now, imagine that (your loved one) is standing here beside you. He or she hears the diagnosis and the available options the doctor has given. What does he or she want us to do, or not do next? **

Nothing could make that 3:00am phone call any easier, but these four questions increase the likelihood that your surrogate decision will be what “mother” would have chosen for herself. Additionally, using this guide will significantly reduce any guilt or decision-regret that could plague you as a result of having to make such serious choices; instead, you’ll be more likely to view your surrogate decision as “supporting” your mother, father, significant other, or friend.

To avoid placing your own loved ones into this type of situation, I challenge you to select and educate your surrogate decision-maker(s) this week.  Health literacy not only means that you should understand your medical options and choices, it means that your healthcare proxy should understand them as well.

(Click here to download your state’s Advance Directive and get started today!)

About the Author:

Dr. Monica Williams-Murphy is an Emergency Physician, Passionate Patient Education Advocate, End-of-Life Decision-Making Expert and Author of the book, “It’s OK to Die” She is on staff at Huntsville Hospital, one of the largest public health systems in the nation.

For more information and articles on critical and end-of-life decision-making see: http://oktodie.com

**©2011 Fierro’s Four R’s: A Tool for Surrogate Medical Decision-Making. M. Williams-Murphy and D. Fierro. All rights reserved. Used with permission.