AGS has long encouraged the use of oral and written advance directives, or the participation of traditional surrogates, such as close family members, to aid in this process. However, many older patients who lack decisional capacity have neither executed an advance directive nor previously discussed their preferences regarding medical treatments. Even when there are traditional surrogates, there may be disagreement among parties, legal or regulatory obstacles, or other problems that impede decision-making. Except in cases of obvious and complete incapacity, an attempt should always be made to ascertain the patient's ability to participate in the decision-making process. Rationale Respect for autonomous decision-making is a fundamental ethical principle that should be adhered to whenever possible.
Decisional capacity is specific to each patient and to each medical decision.
Patients with mild cognitive impairment may still have decisional capacity for some choices, including the ability to designate a surrogate decision-maker. Furthermore, those who cannot comprehend complex situations may still possess the capacity to make simple decisions, or to convey their opinions regarding the burdens and benefits of ongoing treatments. A nontraditional surrogate, such as a close friend, a live-in companion who is not married to the patient, a neighbor, a close member of the clergy, or others who know the patient well, may, in individual cases, be the appropriate surrogate. Health professionals should make a conscientious effort to identify such individuals. Rationale The most appropriate surrogate for the incapacitated patient is one who has loving and intimate knowledge of the patient's wishes or value systems.