Making Medical Treatment Decisions for Unrepresented Older Adults
Recommendations From Making Medical Treatment Decisions for Unrepresented Older Adults
- The term “unrepresented” should replace the term “unbefriended” when referring to a person who (1) lacks decisional capacity to provide informed consent to a particular medical treatment; (2) has not executed an advance directive that addresses the medical treatment at hand and lacks capacity to do so; and (3) lacks representation from a surrogate decision maker (i.e., family, friend, or legally authorized surrogate).
- National stakeholders should work together to identify best practices and to create more uniform legal standards regarding unrepresented older adults that could be considered for adoption by all states.
- States should expand their laws to explicitly allow nontraditional surrogates to serve as representatives for older adults, and clinicians and healthcare institutions should advocate for the inclusion of nontraditional surrogates whenever appropriate.
- Clinicians, health care organizations, communities, and other stakeholders should work proactively to prevent older adults without potential surrogates from becoming unrepresented.
- 5. Clinicians, health care organizations, communities, and other stakeholders should develop innovative, efficient, and accessible approaches to promote adequate protections and procedural fairness in decision making for unrepresented older adults.
- Medical decision making for unrepresented older adults should include adequate safeguards against ad hoc approaches, seek consensus where possible, and ensure procedural fairness.
- Clinicians should assess medical decision-making capacity in a systematic fashion.
- Clinicians and healthcare institutions should develop, standardize, and systematize methods to make decisions for unrepresented older adults in urgent, life-threatening situations.
- Clinicians and healthcare institutions should ensure that patients with long-term incapacity have longitudinal access to a decision-making surrogate who is familiar with the patient's medical condition and specific circumstances.
- When applying the best interest standard to unrepresented older adults, institutional committees should synthesize all available evidence, and should take steps to guard against perpetuating forms of potential bias in decision making for this highly vulnerable population.
Recommendation Grading
Disclaimer
Overview
Title
Making Medical Treatment Decisions for Unrepresented Older Adults
Authoring Organization
American Geriatrics Society
Publication Month/Year
November 30, 2024
Last Updated Month/Year
December 10, 2024
Document Type
Consensus
Country of Publication
US
Document Objectives
This paper is an official position statement of the American Geriatrics Society (AGS) and updates the 2017 AGS position statement, Making Medical Treatment Decisions for Unbefriended Older Adults. In this updated position statement, the term "unbefriended" is replaced by "unrepresented" as a term that is more value-neutral, more accurately describes the circumstance in which a person without medical decision-making capacity does not have recognized surrogate representation, and better aligns with increasingly preferred terminology as reflected in recent medical literature. We define unrepresented older adults as those who (1) lack decisional capacity to provide informed consent for a particular medical treatment, (2) have not executed an advance directive that addresses the medical treatment at hand and lack capacity to do so, and (3) lack representation from a surrogate decision-maker (i.e., family, friend, or legally authorized surrogate). Making medical decisions on behalf of unrepresented older adults is exceptionally challenging and, given demographic trends, is likely to become increasingly common in the years ahead. The process of arriving at treatment decisions for this population should follow standards of procedural fairness and include capacity assessment, search for potential surrogates, team-based efforts to determine the patient's values and preferences, and steps to guard against bias. Proactive measures are needed to identify older adults at risk for becoming unrepresented. This position statement also calls for national efforts to reduce state-to-state variability in legal approaches for unrepresented patients.
Inclusion Criteria
Male, Female, Older adult
Health Care Settings
Ambulatory, Hospital, Outpatient
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Counseling, Management
Keywords
older adults
Source Citation
Dixon JD, Josyula AV, Javier NM, Zweig Y, Singh M, Kim L, Thothala N, Farrell TW. American Geriatrics Society position statement: Making medical treatment decisions for unrepresented older adults. J Am Geriatr Soc. 2024 Nov 30. doi: 10.1111/jgs.19288. Epub ahead of print. PMID: 39614758.