Hastings Cent Rep. 2017 Jan;47(1):29-31. doi: 10.1002/hast.671.
When a patient lacks decision-making capacity and has not left a clear advance directive, there is now widespread agreement that patient-designated and next-of-kin surrogates should implement substituted judgment within a process of shared decision-making. Specifically, after discussing the "best scientific evidence available, as well as the patient's values, goals, and preferences" with the patient's clinicians, the patient-designated or next-of-kin surrogate should attempt to determine what decision the patient would have made in the circumstances. To the extent that this approach works, it seems to provide about as much respect for the autonomy of incapacitated patients as we could ask for. But, as articles in this issue of the Report by Jeffrey Berger and by Ellen Robinson and colleagues emphasize, reality presents challenges.
当患者缺乏决策能力且未留下明确的预先指示时，现在广泛达成共识，即应在共同决策过程中，由患者指定的代理人或近亲代理人来实施替代判断。具体来说，在与患者的临床医生讨论了“现有最佳科学证据以及患者的价值观、目标和偏好”之后，患者指定的代理人或近亲代理人应尝试确定在这种情况下患者会做出什么样的决策。在这种方法有效的范围内，它似乎为丧失能力的患者提供了尽可能多的自主性尊重。但是，正如杰弗里·伯格（Jeffrey Berger）和艾伦·罗宾逊（Ellen Robinson）及其同事在本期报告中的文章所强调的那样，现实提出了挑战。
