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Am J Respir Crit Care Med. 2012 Sep 15;186(6):480-6. doi: 10.1164/rccm.201204-0710CP. Epub 2012 Jul 19.

The facilitated values history: helping surrogates make authentic decisions for incapacitated patients with advanced illness.

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Division of Geriatric Medicine and Center for Aging and Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.


Many patients who develop incapacitating illness have not expressed clear treatment preferences. Therefore, surrogate decision makers are asked to make judgments about what treatment pathway is most consistent with the patient's values. Surrogates often struggle with such decisions. The difficulty arises because answering the seemingly straightforward question, "What do you think the patient would choose?" is emotionally, cognitively, and morally complex. There is little guidance for clinicians to assist families in constructing an authentic picture of the patient's values and applying them to medical decisions, in part because current models of medical decision making treat the surrogate as the expert on the patient's values and the physician as the expert on technical medical considerations. However, many surrogates need assistance in identifying and working through the sometimes conflicting values relevant to medical decisions near the end of life. We present a framework for clinicians to help surrogates overcome the emotional, cognitive, and moral barriers to high-quality surrogate decision making for incapacitated patients.

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