In critical care, how should decisions be made in cases where a patient lacks decision-making capacity?

• A. Prioritize beneficence exclusively.
• B. Respect autonomy only if there is an advance directive.
• C. Balance autonomy with beneficence and use surrogates or advance directives, with ongoing communication.
• D. Leave the decision to the treating physician.

Answer: (C)

When a patient cannot participate in decisions, care should be guided by a process that respects the patient’s values and preferences while also aiming for beneficial, non-harmful care. The best approach uses any advance directive to inform decisions, relies on a designated surrogate to express what the patient would have wanted (substituted judgment) or, if that isn’t possible, uses the patient’s best interests, and maintains ongoing, open communication among the care team, surrogates, and the patient (if feasible). This combination honors autonomy through prior directions and surrogate input, while ensuring beneficence by tailoring choices to what would most benefit the patient in the current situation and adjusting as circumstances change.

Prioritizing beneficence alone can override the patient’s values and preferences. Respecting autonomy only if there is an advance directive misses the role of surrogates and the need for guidance when directives are incomplete or not applicable to the current scenario. Leaving decisions entirely to the treating physician excludes patient and family involvement and fails to incorporate what the patient would have chosen, leading to care that may not align with the patient’s values.