Identifying an appropriate surrogate – Effectiveness of legislation

Crucial health care decisions, particularly at end of life, are increasingly being made by substitute decision makers (SDM’s). The moral right of surrogates to make life and death decisions on behalf of people made incompetent through illness is well accepted, both by the law and the general public. But Australian jurisdictions are unusual (indeed almost unique) in having produced legislation giving surrogates legal authority for these decisions. Almost all (except WA) allow the patient to appoint somebody specifically for this purpose.

The choice of a surrogate is important, as this person will have a major role in the event the patient becomes incompetent and needs a serious treatment choice to be made (both of which circumstances are becoming the norm). But how does this all work in practice?

We report a single-centre study at a tertiary referral ICU in NSW where we examined:

 1. The process the hospital used in identifying preferred substitute decision makers (SDM)

 2. The correlation between admission names entered and those identified by legislation.

 3. Patient preferences (where known).

The results show a poor correlation, consistent with the only other (US) study of this kind.

It is clear that efforts must be made to improve identification of preferred SDMs in acute care. We describe a proposal for this, and a statewide electronic system.