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. 2015 Oct;175(10):1687-91.
doi: 10.1001/jamainternmed.2015.3956.

Guardianship and End-of-Life Decision Making

Affiliations

Guardianship and End-of-Life Decision Making

Andrew B Cohen et al. JAMA Intern Med. 2015 Oct.

Abstract

As the population ages, more adults will develop impaired decision-making capacity and have no family members or friends available to make medical decisions on their behalf. In such situations, a professional guardian is often appointed by the court. This official has no preexisting relationship with the impaired individual but is paid to serve as a surrogate decision maker. When a professional guardian is faced with decisions concerning life-sustaining treatment, substituted judgment may be impossible, and reports have repeatedly suggested that guardians are reluctant to make the decision to limit care. Physicians are well positioned to assist guardians with these decisions and safeguard the rights of the vulnerable persons they represent. Doing so effectively requires knowledge of the laws governing end-of-life decisions by guardians. However, physicians are often uncertain about whether guardians are empowered to withhold treatment and when their decisions require judicial review. To address this issue, we analyzed state guardianship statutes and reviewed recent legal cases to characterize the authority of a guardian over choices about end-of-life treatment. We found that most state guardianship statutes have no language about end-of-life decisions. We identified 5 legal cases during the past decade that addressed a guardian's authority over these decisions, and only 1 case provided a broad framework applicable to clinical practice. Work to improve end-of-life decision making by guardians may benefit from a multidisciplinary effort to develop comprehensive standards to guide clinicians and guardians when treatment decisions need to be made.

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Conflict of interest statement

Conflicts of interest: No conflicts of interests to disclose.

Figures

Figure
Figure. Instructions about End-of-Life Decisions in State Guardianship Statutes
Each state and the District of Columbia was placed into one of three groups: (1) statute contains no language about end-of-life decisions (shown in grey); (2) statute prohibits a guardian from making end-of-life decisions without court approval (shown in black); or (3) statute permits a guardian to make end-of-life decisions independently (shown in white). Exceptions to these laws are noted. aExceptions exist in statutes in Alaska, Kansas, Montana, Oklahoma, and Vermont. bExceptions exist in all statutes.

Comment in

References

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    1. Terminology concerning guardianship is complex, varies by jurisdiction, and has changed over time. This article uses the term guardian to mean a guardian of person, who is charged with making decisions about the well-being of another, including health care decisions. The court may also appoint a guardian of estate to make decisions about an individual’s property. An individual can have either kind of guardian or both; these roles can be performed by the same person or by different people. In some states, the word conservator is used to mean guardian of estate, while in other states there are conservators of person and conservators of estate and the word guardian is used for minors and persons with intellectual disabilities.

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