Substitute Decision Maker (SDM)

If a patient is incapable of making decisions about medical care, there is a need for a Substitute Decision Maker (SDM). Many patients in intensive care units are not capable of making decisions about treatments. Please click here for more information: 

What are the responsibilities of the Substitute Decision Maker?

The Substitute Decision Maker (SDM) is legally required to make decisions on behalf of the patient. The SDM must try to make a decision based on what the patient would want.

• If the SDM knows about the patient’s wishes for medical care, then the SDM must give or refuse consent for treatments in keeping with those wishes -- even if the decision might not be best for the patient’s immediate health.
• Some patients express wishes in advance by talking to family members or creating a Living Will. Click here to learn more about a Living Will, or Advance Care Planning. These are important sources of information that the SDM should share with the patient’s care team.

What if the patient did not previously express any wishes about medical care?

If the SDM is not aware of relevant healthcare wishes, the SDM must decide on the basis of what seems to be in the patient’s best interest. To do this, the SDM must take into account:

• The values and beliefs that the patient held before the critical illness (e.g., was eating, talking, ambulating, interacting with family important for the patient);
• Whether the treatment being considered is likely to improve or stabilize the patient’s condition, and to eventually achieve a quality of life that the patient will find acceptable;
• What will likely happen if the patient does not receive the treatment;
• The side effects, risks, discomfort involved in the treatment being considered;
• Alternative treatments, if appropriate.

How can I convey the patient’s previously established wishes, such as no CPR and no escalation of care?

You may convey the patient's previously stated wishes to any member of the care team.

• The team will usually discuss these wishes during a meeting with you, but please feel free to raise this issue at other times.
• The care team needs to know your loved one’s wishes in order to provide the best care possible.

Will the SDM have to provide consent for every treatment the patient receives?

The team will not formally ask for consent for low-risk interventions. In fact, agreeing to be admitted to an ICU implies consent to many of the routine procedures – unless the team has been advised otherwise.

Not every patient will want all interventions. The key points to keep in mind:

• Patients have the right to not receive treatments that they don’t want.
• Consent can be withdrawn at any time.
• Inform the team if you are aware of any particular interventions that your loved one wants to avoid.

Unless there is an emergency or a treatment is already known to have been declined by the patient in advance, the team will have a formal discussion with the patient or the SDM about major interventions. The discussion includes a description of risks and benefits of the proposed treatment and its alternatives.

Can the patients or their SDMs ask for certain treatments?

Patients or their Substitute Decision Makers can ask for certain treatments, but do not have the absolute right to receive every treatment that they might request.

For a medical treatment to proceed, there must not only be a patient willing to receive it, but also a physician willing to offer and supervise the treatment.