The Unbefriended - Patients without Surrogates

I just finished editing a comprehensive review of the various mechanisms by which treatment decisions are made for the unbefriended, patients without surrogates.  Most authors addressing the strengths and weaknesses of existing decision-making mechanisms invoke the language of balance and equilibrium.  Muriel Gillick, for example, writes that “a balance must be struck between the need to protect [the unbefriended] from caregiver bias and institutional self-interest, on the one hand, and a stranger’s excessive distance on the other.”  Diane Meier writes that the decision-maker must be “responsive yet independent.” 

This "balancing" is also a central issue in medical futility debates.  On the one hand, we want a decision-making process that is accessible, quick, convenient, and cost-effective.  Example: the Texas Advance Directive Act approach.  But, on the other hand, we want a process that provides the important safeguards of expertise, neutrality, and careful deliberation.