Pope Thaddeus Mason, Sellers Tanya
Health Law Institute, USA.
J Clin Ethics. 2012 Spring;23(1):84-96.
This issue's "Legal Briefing" column covers recent legal developments involving medical decision making for unbefriended patients. These patients have neither decision-making capacity nor a reasonably available surrogate to make healthcare decisions on their behalf. This topic has been the subject of recent articles in JCE. It has been the subject of major policy reports. Indeed, caring for the unbefriended has even been described as the "single greatest category of problems" encountered in bioethics consultation. Moreover, the scope of the problem continues to expand, especially with rapid growth in the elderly population and with an increased prevalence of dementia. Unfortunately, most U.S. jurisdictions have failed to adopt effective healthcare decision-making systems or procedures for the unbefriended. "Existing mechanisms to address the issue of decision making for the unbefriended are scant and not uniform". Most providers are "muddling through on an ad hoc basis". Still, over the past several months, a number of state legislatures have finally addressed the issue. These developments and a survey of the current landscape are grouped into the following 14 categories. The first two define the problem of medical decision making for the unbefriended. The remaining 12 categories describe different solutions to the problem. The first six of these solutions are discussed in this article (Part 1). The last eight solutions will be covered in the Summer 2012 issue of JCE (Part 2). 1. Who are the unbefriended? 2. Risks and problems of the unbefriended. 3.
advance care planning, diligent searching, and careful capacity assessment. 4. Decision-making mechanisms and standards. 5. Emergency exception to informed consent. 6. Expanded default surrogate lists: close friends. 7. Private guardians. 8. Volunteer guardians. 9. Public guardians. 10. Temporary and emergency guardians. 11. Attending physicians. 12. Other clinicians, individuals, and entities. 13. Institutional committees. 14. External committees.
本期的“法律简报”专栏涵盖了近期涉及无亲友患者医疗决策的法律动态。这些患者既无决策能力，也没有合理可得的代理人代表他们做出医疗决策。这个话题一直是《联合委员会杂志》近期文章的主题。它也是主要政策报告的主题。事实上，照顾无亲友患者甚至被描述为生物伦理咨询中遇到的“最大类别的问题”。此外，这个问题的范围还在不断扩大，尤其是随着老年人口的快速增长和痴呆症患病率的上升。不幸的是，美国大多数司法管辖区都未能为无亲友患者采用有效的医疗决策系统或程序。“解决无亲友患者决策问题的现有机制很少且不统一”。大多数医疗服务提供者“在临时基础上摸索前行”。尽管如此，在过去几个月里，一些州立法机构终于着手解决这个问题。这些动态以及对当前情况的调查被归为以下14类。前两类界定了无亲友患者医疗决策的问题。其余12类描述了针对该问题的不同解决方案。本文（第1部分）讨论了其中的前六种解决方案。最后八种解决方案将在《联合委员会杂志》2012年夏季刊（第2部分）中介绍。1. 谁是无亲友患者？2. 无亲友患者的风险和问题。3. 预防措施：预先护理规划、认真查找和仔细的能力评估。4. 决策机制和标准。5. 知情同意的紧急例外情况。6. 扩大默认代理人名单：亲密朋友。7. 私人监护人。8. 志愿监护人。9. 公共监护人。10. 临时和紧急监护人。11. 主治医生。12. 其他临床医生、个人和实体。13. 机构委员会。14. 外部委员会。
