title: Limitations on surrogate decision-making for emergent liver transplantation.
abstract: BACKGROUND
  Surrogate consent is an accepted form of promoting patient autonomy when patients cannot consent, but it can lead to surrogate duress and may be unreliable. Since consent for liver transplantation in patients with fulminant hepatic failure (FHF) is typically performed by surrogates and these patients typically regain decisional capacity, we chose this population to query patients' opinion on the surrogate consent process.
  
  
  METHODS
  We developed a questionnaire that queried transplanted patients' experience and opinion on surrogate consent, suitability of surrogates, and return of decisional capacity. This survey was then sent to consecutive survivors of liver transplantation for FHF at our institution.
  
  
  RESULTS
  Eleven of 14 patients eligible to participate completed the questionnaire. The mean follow-up for all survivors was 41 mo, with a range of survival since transplant of 5 mo to 10 y. Although 10/11 respondents agreed with their surrogates to consent to liver transplantation, all 11 patients thought that surrogates should not be able to decline liver transplantation for this condition. In distinction, 3/11 patients believed patients could decline liver transplantation.
  
  
  CONCLUSIONS
  This is the first study to demonstrate that liver transplant patients do not think surrogate decision-makers should be permitted to contravene physician recommendations regarding transplant. In clinical settings when patients cannot speak for themselves, it may be appropriate for surrogates and clinicians to act together according to the patients' best interest rather than attempt to determine what the patient would want. This approach might reduce surrogate distress, better represent patient preferences, and improve the decision-making process for affected patients.
authors.affiliation: Department of Surgery, Emory University Hospital, Atlanta, Georgia, USA. lukebrewst@aol.com
authors.forename: Luke P
authors.initials: LP
authors.lastname: Brewster
authors.forename: Jason
authors.initials: J
authors.lastname: Palmatier
authors.forename: C J
authors.initials: CJ
authors.lastname: Manley
authors.forename: Daniel E
authors.initials: DE
authors.lastname: Hall
authors.forename: J J
authors.initials: JJ
authors.lastname: Brems
mesh_terms: D000328:Adult; D003657:Decision Making / Q000941:ethics*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D017114:Liver Failure, Acute / Q000601:surgery*; D016031:Liver Transplantation / Q000941:ethics*; D008297:Male; D008875:Middle Aged; D010344:Patient Advocacy; D026684:Personal Autonomy; D012189:Retrospective Studies; D011795:Surveys and Questionnaires