A philosophical discussion of end-of-life decision-making methods for incompetent patients

This article provides an analysis of decision-making methods that can be used with incompetent patients (patients who are unable to make decisions for themselves). It is intended as a general discussion of the relevant issues rather than an examination of legal or policy concerns. The advance directive principle (whereby a person leaves instructions for what to do if they become unable to make their own decisions) is discussed with reference to practical and philosophical issues. Substituted judgement (where surrogate decision makers make decisions that the patient who is incompetent would make if competent) is then discussed followed by the principle of best interests, which requires consideration beyond purely medical interests. The need to make patient-centred quality-of-life judgements as a component of best interests decisions is argued. Conclusions reached include the notion that the advance directive principle and the substituted judgement principle facilitate the concept of self-determination. The best interests principle helps to ensure that patients ending up in this vulnerable position are protected.