Hierarchy of Medical Decision-Making Authority for Incapacitated Patients

Primary Decision-Making Authority: Healthcare Proxy/Agent

A healthcare proxy designated through a durable power of attorney for health care or health and welfare Lasting Power of Attorney (LPA) takes precedence over all other decision-makers when the patient lacks capacity, as chosen by the patient while they had capacity to make decisions on their behalf 1, 2, 3, 4
The healthcare proxy can only act once the patient has actually lost capacity for that specific decision, and must review the LPA document itself for limits to their authority, particularly regarding life-sustaining treatment decisions 2, 3, 4

When no healthcare proxy exists, or when the proxy cannot fulfill their role, courts may appoint a guardian, conservator, or conservator of the person, who can make some healthcare decisions depending on their appointment terms, but cannot refuse life-sustaining treatment 1, 2, 3, 5

In states with default surrogacy statutes, when no advance directive or durable power of attorney exists, a hierarchy of family members is empowered to make decisions, typically in the order of spouse, adult child, parent, sibling, and friend 2, 3
Not all U.S. states have default surrogacy statutes, and in states without such statutes, court appointment of a guardian becomes necessary if a patient lacks capacity and has no healthcare agent 1, 3

When a patient lacks capacity and has no valid surrogate, the treating physician makes treatment decisions based on the patient's best interests, considering medical factors, previously expressed values and beliefs, general well-being, and spiritual/religious welfare 1, 2, 3, 4, 5
The American Medical Association and other medical societies recommend that physicians prioritize the patient's best interests and previously expressed wishes when making decisions for incapacitated patients 2, 4, 5
The patient's best interests encompass medical factors, the patient's previously expressed values and beliefs, general well-being, and spiritual/religious welfare, according to the American Academy of Family Physicians and other medical organizations 1, 4, 3