The most critical element in surrogate consent is establishing the legal standing
of the surrogate. Physicians are frequently confronted with friends or relatives
of an incompetent patient who claim to be the patient’s guardian. It is
imperative that these persons be asked to provide a copy of the legal order
that establishes their status as guardian. A copy of this order should be made a
part of the patient’s chart and should be referred to in every consent form.
In most cases, guardianship proceedings are uncontested. The proceedings are
instituted by a family member, social worker, medical care provider, or other
concerned person for the protection of the incompetent person. The
incompetent’s friends and relatives, if any, may testify that the appointment of
the guardian is in the patient’s best interests. In uncontested guardianships,
consent for medical care should be documented in the same way as a consent
from a competent patient. The same type of chart note and consent form
should be used, with the additional language about the consent being obtained
from the guardian.
Some guardianships are contested. The most common contest involves the
appointment of a guardian to consent to medical care for a child whose parents
do not want the child treated. The duty to inform the guardian is the same in
these cases, but the necessary documentation is more extensive. In addition to
incorporating the guardianship papers in the patient’s medical record, an
attorney should review these papers to ensure that they are in order. This
review is to determine if there are any limitations on the guardian’s authority.
Since these cases usually involve hospitalization, the physician should also
discuss the guardianship with the hospital’s attorney.
Once a guardian has been appointed for a given purpose, the court does not
second- guess the guardian’s decisions. It does attempt to ensure that the
guardian is acting properly, and persons may ask the court to remove the
guardian if they believe that he or she is acting improperly. If a physician is
treating a patient who has a guardian, the physician does not need to ask the
court to approve each of the guardian’s decisions. The physician should be
prepared to explain how he or she and the guardian arrived at those decisions.
Physicians treating patients with contentious guardianship arrangements
should ensure that all decisions by the guardian are carefully documented in
the medical record.