Commentary: The Reluctant Surrogate

An individual's hesitance or outright refusal to function as a substitute decisionmaker creates a number of challenges for treating teams, as is highlighted by the case of KS. It is not uncommon for individuals who suddenly find themselves in the role of substitute decisionmaker (SDM) to experience feelings of inadequacy or of being overwhelmed. The natural apprehension that comes with realizing, or being informed, that you are now responsible for providing or refusing consent on behalf of a loved one is often exacerbated by the accompanying circumstances. Even though there are movements afoot to encourage and support advance care planning and the inclusion of those who will become SDMs in conversations about values and wishes, there is still much work to be done. Although the case as presented does not provide information regarding what, if any, processes have taken place prior to the current hospital admission with regard to including the patient's sister in discussions about future circumstances, it is clear that the sister feels unprepared to assume the role being thrust upon her. What, then, does a clinical ethics consultation have to offer in such situations? The following discussion highlights three ways in which ethics consultation can be of value to both the treating team and the identified SDM: ethics consultation (1) helps the care team and SDM navigate the regulatory landscape, (2) supports the treating team, and (3) supports the SDM.