High D M
Department of Philosophy, University of Kentucky, Lexington.
Clin Geriatr Med. 1994 Aug;10(3):445-62.
The necessity of surrogate decision making arises for geriatric patients who can no longer make decisions for themselves. Almost every clinical situation involves some assessment of a patient's decisional capacity. Because decisional capacity is decision specific and entails the ability to manipulate information, it is best to conduct functional evaluations and use psychiatric measurements for dementia cautiously in determining decisional capacity. Traditionally, the medical community has relied on family members to be surrogate decision makers when a patient is assessed as decisionally incapacitated. That practice still has moral warrant, even amid advocacy for the use of advance directives, because most people have not completed such planning instruments. The family as a primary social unit is likely the most concerned for the welfare and wishes of the patient. These theoretical grounds are supplemented by emerging empirical evidence that elderly patients themselves almost always prefer that family members serve in the role of surrogate decision makers. Dealing with family surrogates obliges the geriatrician to ensure that failures in communication do not arise and that conflicts of interest are avoided in protecting the best interests of the patient. Although recent legal climate has shown a preference for a substituted judgment standard in surrogate decision making, medical concern for the best interests of the patient, together with empirical evidence that the elderly are most interested in decisions that arise out of trusted interdependencies, suggests that rules and laws are no substitute for the good faith human actions of trusted surrogates.
对于那些无法再为自己做决定的老年患者而言，代理决策变得很有必要。几乎每种临床情况都涉及对患者决策能力的某种评估。由于决策能力是特定于决策的，并且需要处理信息的能力，因此在确定决策能力时，最好谨慎地进行功能评估并使用针对痴呆症的精神科测量方法。传统上，当患者被评估为无决策能力时，医学界一直依赖家庭成员作为代理决策者。即使在提倡使用预先指示的情况下，这种做法仍然具有道德依据，因为大多数人尚未完成此类规划文件。作为主要社会单位的家庭可能最关心患者的福利和意愿。这些理论依据得到了新出现的实证证据的补充，即老年患者自己几乎总是希望家庭成员担任代理决策者的角色。与家庭代理人打交道迫使老年病医生确保不会出现沟通失误，并在保护患者的最佳利益时避免利益冲突。尽管最近的法律环境显示出在代理决策中倾向于采用替代判断标准，但对患者最佳利益的医学关注，以及老年人对源于信任的相互依赖关系所产生的决策最感兴趣的实证证据表明，规则和法律无法替代可信赖代理人的真诚的人为行动。
