The patient did not have an advance directive after a stroke; who is responsible for making end-of-life decisions when the patient cannot communicate his or her wishes?

• A. Physician and family
• B. Notary and attorney
• C. Wife and adult children
• D. Physician and nursing staff

Answer: (C)

When there’s no advance directive, someone closest to the patient must act as a surrogate decision-maker. The spouse is the primary surrogate, with adult children next in line to represent what the patient would want. Decisions are guided by substituted judgment (what the patient would have chosen) and, if that isn’t knowable, the best interests of the patient. Notaries or attorneys don’t automatically assume this role unless they’ve been named in a durable power of attorney for healthcare. The physician is responsible for providing medical advice, and the care team works with the surrogate, but the surrogate (typically the wife and adult children) makes the concrete end-of-life decisions.