Alternative Healthcare Decision Making Options for Unrepresented Patients

Photo Taken In Bangkok, Thailand
The author investigates the use of a regional state unrepresented patient advocacy committee as an alternative to appointing legal guardians or using physicians as decision makers.

Regional state unrepresented patient advocacy committees (UPACs) can be an effective alternative to a legal guardian or physicians as decision makers for patients with decisional incapacity who lack an advance healthcare directive, according to an article published in the AMA Journal of Ethics.

The majority of the adults in the United States do not have any form of advance healthcare directive, and ≤70% of the elderly unrepresented patients lack decision-making capacity near the end of life. Many of these unrepresented patients are admitted into the healthcare system through an emergency or as a transfer from an extended care facility with no contact information of family or friends. The search for the legal decision maker starts when there is a need for legal informed consent or a discharge plan. If there is no information about the friends and family of the patient, the institution will start the process of naming a legal guardian. A common solution is state guardianship, which is very time-consuming and costs the institution thousands of dollars to process.

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The author has listed different potential surrogates for unrepresented patients as an alternative to legal guardians: the attending physician, in consultation with another physician; the attending physician along with institutional ethics committee representatives; institutional ethics committee chair and committee subgroup; and regional UPACs. 

According to the author, UPACs are the most potentially advantageous. Each UPAC will be composed of multidisciplinary healthcare professionals and a community advocate, who review the patient’s condition and treatment goals with the members of the treatment team; hence, there is a quick response. In this process, the UPAC would interact with the healthcare institution’s ethics committee, treatment team, and other institutional stakeholders to assist with medical and treatment decisions on behalf of the patient until a permeant legal decision maker is identified. There are yet no existing UPACs, but they would have to be organized by the state governments with clear guidelines for transparency. Unrepresented patient advocacy committees have to set up by region, depending on the population size, healthcare institutions, and demographics. The members of the committee have to undergo background checks as well as orientation and training similar to state guardians. To gain and maintain the trust of the public being served, proper monitoring, oversight, and evaluation systems have to be established.

The author concluded, “More research needs to be done regarding the exact logistics of setting up the regional committees as well as how a more permanent legal decision maker for unrepresented persons would be named. Nevertheless, the UPAC can be seen as an efficient short-term solution for what could be a long-term need.”


Anderson-Shaw LK. Regional unrepresented patient advocacy committee as an alternative for decision making. AMA J Ethics. 2019;21(7):E594-E599.

This article originally appeared on Medical Bag