When Surrogates Choose Suffering A commentary

In modern era medicine, patient’s autonomy is held in the epitome of medical decision making. When patients lose decision making capacity, providers try to the best of their ability to uphold patient’s pre-expressed wishes, often using substituted judgment. The goal is to answer: What is in the patient’s best interest and what would the patient want if they could speak for themselves? But what happens when providers feel that patient’s best interests are not being put front and center? In addition, substituted judgment is considered a basic guiding principle when making decisions for incapacitated patients; but literature illustrates that this framework is not free of fault. We present a case of a 70-year-old male with a diagnosis of terminal colon cancer with metastasis to the brain, lung, and bones who presented with complaints of weakness and altered mental status. Although the patient could not speak, he exhibited signs and symptoms of severe pain. The surrogate refused to provide the patient with analgesics. The ethics committee was consulted to help navigate the situation and facilitate a solution. Though the pursuit of substituted judgment is well-intended, it is not infallible. It is important to recognize this when having discussions with surrogate decision makers and understanding that alternative models could be a better fit in certain situations. All while trying to the best of the provider’s ability to uphold patient’s wishes and best interests.