Send to

Choose Destination
J Am Geriatr Soc. 2019 May 6. doi: 10.1111/jgs.15957. [Epub ahead of print]

Ethical Challenges in Caring for Unrepresented Adults: A Qualitative Study of Key Stakeholders.

Author information

College of Medicine, California Northstate University, Elk Grove, California.
Division of Geriatrics, University of California, San Francisco, San Francisco, California.
Division of General Internal Medicine, University of California, San Francisco/San Francisco General Hospital and Trauma Center, San Francisco, California.


The decision-making process on behalf of unrepresented adults (ie, those who lack capacity to make medical decisions and have no identifiable surrogate) is at risk for not incorporating their interests, raising ethical concerns. We performed semistructured interviews with key stakeholders across multiple sectors in an urban county who participate in the care of or decision-making process for unrepresented adults. This included a safety net healthcare system, social services, and legal services. Participants were healthcare, social service, and legal professionals who worked with unrepresented adults (n = 25). Our interview questions explored the current process for proxy decision making in cases of unrepresented adults and potential alternatives. We recorded, transcribed, and analyzed interviews using the constant comparative method to identify major themes related to ethical challenges if they were raised. Participants grappled with multiple ethical challenges around the care of unrepresented adults. Themes described by participants were: (1) prioritizing autonomy; (2) varying safety thresholds; (3) distributing resources fairly; and (4) taking a moral toll on stakeholders. In conclusion, all stakeholders identified ethical challenges in caring for unrepresented adults. An applied ethical framework that takes these dilemmas into account could improve ethical practice for unrepresented adults and lessen the emotional toll on stakeholders. J Am Geriatr Soc, 1-6, 2019.


autonomy; ethical dilemmas; safety; unbefriended; unrepresented; vulnerable populations


Supplemental Content

Full text links

Icon for Wiley
Loading ...
Support Center