Legal briefing: The unbefriended: Making healthcare decisions for patients without surrogates (Part 1)

Journal of Clinical Ethics

Volumn 23, Issue 1, 2012, Pages 84-96

  Pope, Thaddeus Mason ^a,b   Sellers, Tanya ^c  

^a Health Law Institute   (United States)

^b HAMLINE UNIVERSITY   (United States)

^c WIDENER UNIVERSITY   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; DECISION MAKING; EMERGENCY; ETHICS; HUMAN; INFORMED CONSENT; LEGAL ASPECT; PATIENT CARE; STANDARD; UNITED STATES;

ADVANCE CARE PLANNING; DECISION MAKING; EMERGENCIES; ETHICS CONSULTATION; HUMANS; INFORMED CONSENT; PATIENT CARE MANAGEMENT; UNITED STATES;

EID: 84860337139     PISSN: 10467890     EISSN: None     Source Type: Journal    
DOI: None     Document Type: Article

References (167)

1. I. Hyun et al., "When Patients Do Not Have a Proxy: A Procedure for Medical Decision Making When There Is No One to Speak for the Patient", The Journal of Clinical Ethics 17, no. 4(2006):323-30;
2. D. M. Bartels et al, "Dignity Matters: Advance Care Planning for People Experiencing Homelessness", The Journal of Clinical Ethics 19, no. 3(2008):214-22.
3. N. Karp and E. Wood, Incapacitated and Alone: Healthcare Decision Making for Unbefriended Older People (Washington, D. C.: American Bar Association, 2003);
4. When Others Must Choose: Deciding for Patients without Capacity, (Albany, N. Y.: New York State Task Force on Life and the Law, March 1992), Chapter 10;
5. J. E. B. Ortiz, Advocating for the Unbefriended Elderly: An Informational Brief (Washington, D. C.: National Consumer Voice for Quality Long-Term Care, August 2010), http://www.ltcombudsman.org/sites/default/files/ombudsmen-support/ training/Informational-Brief-on-Unbefriended-Elders-0.pdf, accessed 27 January 2012;
6. Center for Advocacy for the Rights and Interests of the Elderly (CARTE), White Paper: Meeting the Needs of Persons with Alzheimer's or Other Dementia When No Informal Support is Available, October 2010, http://www.carie.org/ alzheimers-white-paper/, accessed 27 January 2012.
7. (quoting Nancy Dubler). The issue has also been described as "one of the most difficult problems in medical decision-making." Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying (Briarcliff Manor, N. Y.: Hastings Center, 1987).
8. M. J. Quinn, Guardianships of Adults: Achieving Justice, Autonomy, and Safety (New York: Springer, 2005): 112.
9. "Only a few states specify a procedure [for a] patient without a surrogate." American Medical Directors Association, "White Paper on Surrogate Decision-Making and Advance Care Planning in Long-Term Care, 2003, http://www.amda.com/governance/whitepapers/surrogate/decisionmaking-hierarchy. cfm, accessed 27 January 2012;
10. J. Sacco, "Incapacitated, Alone, and Treated to Death", New York Times, 7 Oct. 2008.
11. M. B. Kapp, "The 'Voluntary' Status of Nursing Facility Admissions: Legal, Practical, and Public Policy Implications", Criminal and Civil Confinement 24, no. 1(1998):1-35;
12. M. B. Kapp, "Editorial-Surrogate Decision-Making for the Unbefriended: Social and Ethical Problem, Legal Solution?" Journal of Ethics, Law, and Aging 1, no. 2(1995):83-85.
13. This briefing does not address some related issues. First, it does not address decision-making mechanisms for special and extraordinary medical situations such as sterilization and the administration of psychotropic medication. Additional protections are usually required in such situations. E.g. Fla. Stat § 765.113. Second, this briefing does not address the situation in which the incapacitated unbefriended patient "objects" to treatment. Third, while this briefing focuses on healthcare decision making, such decisions are often intertwined with those concerning finances. For example, it might be necessary to authorize someone to sell a patient's property so that she or he can qualify for Medicaid and long-term care placement. Fourth, this briefing does not address the participation of the unbefriended in biomedical research.
14. T. M. Pope, "Legal Fundamentals of Surrogate Decision Making", Chest 141(2012): in press.
15. N. Karp and E. Wood, "Incapacitated and Alone: Healthcare Decision Making for Unbefriended Older People", Human Rights 31, no. 2(2004):20-4.
16. Minnesota Commission on End-of-Life Care, "Final Report", January 2002, p. 54, http://www.mnhpc.org, accessed 27 January 2012.
17. C. Frank, "Surrogate Decision-Making for 'Friendless' Patients", Colorado Lawyer 34, no. 4(April 2005):71-6;
18. California Law Review Commission, "Memorandum 98-63: Health Care Decisions: Comments on Tentative Recommendation", (18 September 1998): 9, www.clrc.ca.gov/pub/1998/M98-63.pdf, accessed 27 January 2012.
19. V. Kind, The Caregiver's Path to Compassionate Decision Making (Austin, Tex: Greenleaf Book Group, 2010): 46-8.
20. L. F. Post, J. Blustein, and N. N. Dubler, Handbook for Healthcare Ethics Committees (Baltimore, Md.: Johns Hopkins University Press, 2007): 205-8;
21. American Health Decisions, "The Patient Alone: Making Health Care Choices for Patients without Surrogates", 6-7 May 2008, http://www.ahd.org/Presentations-% 26-Faculty.html, accessed 27 January 2012.
22. D. B. White et al., "Life Support for Patients without a Surrogate Decision Maker: Who Decides?" Annals of Internal Medicine 147, no. 1(2007):34-40;
23. D. B. White et al., "Decisions to Limit Life-Sustaining Treatment for Critically Illl Patients Who Lack Both Decision-Making Capacity and Surrogate Decision-Makers", Critical Care Medicine 34, no. 8(2006):2053-9;
24. S. J. Baumrucker et al., "A Cognitively Impaired Patient without a Surrogate: Who Makes the Decision?" American Journal of Hospice and Palliative Medicine 28, no. 8(2011):583-7;
25. C. Griggins, "Patients without Proxies: What's Happening in Other States?" Mid-Atlantic Ethics Committee Newsletter (Summer 2010): 7-9;
26. A. Robichaud and C. Griggins, "Patients without Proxies: Medical Decision-Making for Patients without Advocates", PowerPoint presentation for Cleveland State University, 18 Nov. 2010, http://wapps. csuohio.edu/ campusmailbag/forum-posts. asp?TID=6308, accessed 10 February 2012.
27. N. J. A. B. 4098, 214th Legis. (2011) (Conaway).
28. E. D. Isaacs and R. V. Brody, "The Unbefriended Adult Patient", San Francisco Medicine (July/August 2010): 25-6;
29. M. Varughese et al., "Ethics and Clinical Practice Guided by the Family Health Care Decisions Act", NYSBA Health Law Journal 16, no. 1(2011):75-82;
30. R. M. Gibson, "IDT Decision-Making in California Long-Term Care Facilities", California Association of Long-Term Care Medicine (December 2011), http://caltcm.org/news/dec2011/idt, accessed 27 January 2012;
31. C. P. Sabatino, Advance Directives and Advance Care Planning: Legal and Policy Issues (Washington, D. C.: U. S. Department of Health and Human Services, 2007), http://aspe.hhs. govldaltcplreportsl2007ladacplpi.pdf, accessed 27 January 2012;
32. M. J. Gorbien and A. R. Eisenstein, "Elder Abuse and Neglect: An Overview", Clinics in Geriatric Medicine 21, no. 2(2005):279-92;
33. M. B. Kapp, "Medical Decision Making for Older Adults in Institutional Settings: Is Beneficence Dead in an Age of Risk Management", Issues in Law and Medicine 11, no. 1(1995):29-46;
34. M. A. Williams, "Unbefriended", Neurology 67, no. 11(2006):2088.
35. The term was apparently coined in a symposium of the Journal of Ethics, Law and Aging 1, no. 2 (1995).
36. One article attributes the term to Joanne Lynn. T. E. Finucane, R. D. Elon, and J. M. Keenan, "The Medical Director in Non-Institutional Long-Term Care Programs", Clinics in Geriatric Medicine 11, no. 3(1995):391-402.
37. M. R. Gillick, "Medical Decision-Making for the Unbefriended Nursing Home Resident", Journal of Ethics, Law and Aging 1, no. 2(1995):87-92;
38. T. Miller and A. M. Cugliari, "Withholding and Withdrawing Treatment: Policies in Long-Term Care Facilities", Gerontologist 30, no. 4(1990):462-8.
39. D. Silverman, "Serving the Unbefriended Elder Population: Trends, Challenges, and Successes", PowerPoint presentation, 2011 Minnesota Age & Disabilities Odyssey, Mayo Civic Center, Rochester, Minn., 21 June 2011
40. (citing a study by Andrea Palumbo, Elder Justice Scholar, William Mitchell College of Law), http://www.mnodyssey.org, accessed 27 January 2012.
41. A. Fader, S. Gambert, M. Nash, and K. Gupta, "Implementing a Do-Not-Resuscitate Policy in a Nursing Home", Journal of the American Geriatrics Society 37, no. 6(1989):544-8.
42. L. M. Howden and J. A. Meyer, "Age and Sex Composition: 2010", United States Census Bureau, May 2011, http://www.census.gov/prod/cen2010/ briefs/c2010br-03.pdf, accessed 27 January 2012.
43. N. Karp and E. F. Wood, "Guardianship Monitoring: A National Survey of Court Practices", Stetson Law Review 37, no. 1(2007):143-97.
44. American Academy of Pediatrics, Committee on Pediatric Emergency Medicine and Committee on Bioethics, "Consent for Emergency Medical Services for Children and Adolsescents", Pediatrics 128, no. 2(2011):427-33.
45. J. E. Berger and American Academy of Pediatrics, Committee on Medical Liability, "Consent by Proxy for Nonurgent Pediatric Care", Pediatrics 112, no. 5(2003):1186-95.
46. For example, Michelle Bateman, a 43-yearold woman, remained unconscious in University of Pennsylvania hospital for four months before she was identified and her family located. She went into cardiac arrest on 13 August 2010, was brought to an area hospital, and later transferred to Penn, but never regained consciousness. Because no one could determine her identify and no family members were immediately present, the hospital absorbed all costs of treatment and presumably all decisions relating to the treatment. Her family placed missing person reports and made phone calls, and the hospital ran nationwide fingerprint checks and asked for help from local TV stations and newspapers. Four months later, in December 2010, a friend recognized her picture in the newspaper and contacted her family. D. Sapatkin, "Family Identifies Unconscious Woman", Philadelphia Inquirer, 14 December 2010.
47. J. J. O'Connell, "Raging Against the Night: Dying Homeless and Alone", The Journal of Clinical Ethics 16, no. 3(Fall 2005):262-6;
48. J. Song, E. R. Ratner, and D. M. Bartels, "Dying While Homeless: Is It a Concern When Life Itself Is Such a Struggle?" The Journal of Clinical Ethics 16, no. 3(Fall 2005):251-61;
49. W. M. Norris, E. L. Nielsen, R. A. Engelberg, and J. R. Curtis, "Treatment Preferences for Resuscitation and Critical Care among Homeless Persons", Chest 127, no. 6(2005):2180-7.
50. M. Stiff, Breaking Down Barriers: An Administrator's Guide to State Law and Best Policy Practice for LGBT Healthcare Access (Washington, D. C.: Human Rights Campaign, 2009). Effective in 2012, a new Delaware statute provides that "parties to a civil union⋯ shall have all the same rights, protections and benefits⋯ as are granted to, enjoyed by or imposed upon married spouses"
51. Del. S. B. 30, 146th Gen. Assembly (2011) (Sokola)
52. codified, at 13 Del. Code §§ 201-216.
53. K. Tucker, "Elder Law: Counseling Clients Who Are Terminally Ill", William Mitchell Law Review 37, no. 1(2010):117-31.
54. T. M. Pope, "Comparing the FHCDA to Surrogate Decision Making Laws in Other States", NYSBA Health Law Journal 16, no. 1(2011):107-11;
55. Wash. Rev. Code Ann. § 7.70.065.
56. L. S. Castillo et al., "Lost in Translation: The Unintended Consequences of Advance Directive Law on Clinical Care", Annals of Internal Medicine 154, no. 2(2011):121-8.
57. R. N. Swidler, "New York's Health Care Decisions Act: The Legal and Policy Background, Key Provisions, and Emerging Issues", NYSBA Health Law Journal (June 2010): 18-27.
58. Volunteers of America-Minnesota, "Unbefriended Elders: Matching Values with Decisions", 30 April 2010, http://www.mngero.org/downloads/ UnbefriendedElders.pdf accessed 27 January 2012.
59. See the section, "5. Emergency Exception to Informed Consent", in this column, above.
60. A. Meisel and K. L. Cerminara, The Right to Die: The Law of End of Life Decisionmaking, 3rd ed. (suppl.) (New York: Aspen, 2010), § 3.16 [F].
61. T. E. Miller, C. H. Coleman, and A. M. Cugliari, "Treatment Decisions for Patients without Surrogates: Rethinking Policies for a Vulnerable Population", Journal of the American Geriatrics Society 45, no. 3(1997):369-74, 370. ("Without a surrogate, decisions may be less open, less clearly articulated, and more susceptible to judgments about the patient's social and individual worth.")
62. M. Bornang, "Unbefriended Elders: Matching Values in Decisions", NAELA Bulletin, 25 August 2009;
63. Volunteers of America-Minnesota, "Volunteers of America-Minnesota Wins Grant to Help Unbefriended Elders Convey Healthcare Preferences", 27 August 2008, http://www.voamn.org/About-Us/Press-Room/2008-News-Archive/ Unbefriended-Elders-Grant, accessed 27 January 2012.
64. Volunteers of America-Minnesota, "Unbefriended Elders Project", PowerPoint Presentation, http://www.voamn. org/Learn-Abou t-our-Services/ Senior-Services/Protective-Services/Unbefriended-Elders-Project, accessed 27 January 2012.
65. Public and private "next-of-kin registries" may also be useful in identifying and locating potential surrogates, http://www.nokr.org/, accessed 27 January 2012.
66. N. Y. Pub. Health Code § 2994-g (1) ("Within a reasonable time after admission as an inpatient to the hospital of each adult patient, the hospital shall make reasonable efforts to determine if the patient has appointed a health care agent or has a guardian⋯. With respect to a patient who lacks capacity, if no such health care agent, guardian or potential surrogate is identified, the hospital shall identify, to the extent reasonably possible, the patient's wishes and preferences, including the patient's religious and moral beliefs, about pending health care decisions, and shall record its findings in the patient's medical record.").
67. 42 U. S. C. § 1395cc (f) (l);
68. 42 C. F. R. §§ 482.13 (b) (3) & 489.102 (a) (4).
69. J. Duncan, "Physician Order for Life Sustaining Treatment: Developing a POLST Registry", http://www.naphsis.org, accessed 27 January 2012.
70. D. Sapatkin, "Nearly Four Months Later, Woman at HUP Still Unidentified", Philadelphia Inquirer, 11 December 2010.
71. E.g. Tex. Health & Safety Code § 313.005 (b).
72. L. M. Peterson, "Clinical Decision Making for the Unbefriended Patient", Lahey Clinic Journal of Medical Ethics (Fall 2010): 3.
73. S. F. Cohn and M. H. Rieff, "Care Management Challenges in Serving Un-Befriended Older Adults with Compromised Cognitive Capacity", ASA/NCOA Conference, 29 April 2011, http://www.jarvie.org/docs/Unbefriended-EIder-with- Cogn-Impairment-presentation.pdf, accessed 27 January 2012.
74. Fla. Stat. § 765.401 (h).
75. Ethical Aspects of the Relationship between Clinicians and Surrogate Decision Makers (Washington, D. C.: National Ethics Committee of the Veterans Health Administration, 2007). The policy at Brigham and Women's Hospital suggests "weaving these fragments of experience and knowledge together produces a 'synthetic judgment' of the patient's preferences"
76. N. Sadovnikoff and M. Jurchak, "Substituted Judgment in the Absence of Surrogates", Critical Care Medicine 35, no. 10(2007):2467-8;
77. M. Jurchak, "Creating a Voice for Absent or Inadequate Surrogates", ASBH Annual Meeting, 9 October 2007, http://asbh.confex.com/ asbh/2007/techprogram/P6154. HTM, accessed 27 January 2012.
78. Does I to III v. District of Columbia, No. 01-2398 (HHK) (D. D. C. 30 September 2011) (order granting motion to file second amended complaint).
79. In re Moe, 81 Mass. App. Ct. 136
80. 2012 WL 104915 (17 January 2012).
81. M. Church and S. Watts, "Assessment of Mental Capacity: A Flow Chart Guide", Psychiatrist 31, (2007) 304-07 (reviewing "properly supported processes" sufficient to enable the patient to make the decision in question, such as: multiple learning trials with corrected feedback and enhanced structure using computer-based presentations).
82. M. S. Chin and V. A. Brown, "The Dilemma of Capacity: Respecting Patient Wishes and Preferences and Decision Making Ability", Journal of Hospital Ethics 2, no. 1 (2010).
83. "Old, Sick, and Unbefriended" editorial, Boston Globe, 18 January 2008.
84. In states that utilize the traditional process, substantial efforts are underway to develop practical alternatives and guardian prevention methods. D. P. Smith and S. B. Gardner, "Complex Family Matters in Guardianship, Advanced Elder Law and Advanced Guardianship", in Advanced Guardianship Course 2009 (Houston, Tex.: State Bar of Texas, 2009), chapter 11.
85. For instance, the Texas legislature recently mandated the development of an additional program to assist those individuals with mental disabilities and no guardian in making decisions. The statute requires the Health and Human Services Commission to develop and evaluate two Volunteer Supported Decision-Making Advocate Programs. Tex. H. B. 1454 (2009);
86. Texas Council for Developmental Disabilities, "Alternatives to Guardianship: Volunteer Supported Decision-Making Advocate Pilot 010-06", http://www.txddc.state.tx. us/grants-projects/rfp2010-06.asp, accessed 27 January 2012. The programs will assist these individuals in making life decisions such as where to live and with whom and where to work.
87. AMA Council on Ethical and Judicial Affairs, "Selection of Health Care Decision-Making Surrogates", CEJA Report 3-A-04, http://www.amaassn. org/resources/doc/ethics/3a04.pdf, accessed 27 January 2012.
88. Ethics Committee of the American Geriatrics Society, "Making Treatment Decisions for Incapacitated Older Adults without Advance Directives", Journal of the American Geriatrics Society 44, no. 8(1996):986-7.
89. L. Snyder, "American College of Physicians Ethics Manual, Sixth Edition", Annals of Internal Medicine 156, no. 1(2012):73-104.
90. Ala. Code § 22-8A-11 (c).
91. T. M. Pope, "The Best Interest Standard: Both Guide and Limit to Medical Decision Making on Behalf of Incapacitated Patients", The Journal of Clinical Ethics 22, no. 2(2011):134-8.
92. Ariz. Rev. Stat. § 36-512;
93. Cal. Bus. & Prof. Code § 2397;
94. Cal. Health & Safety Code § 1418.8 (h);
95. Cal. Prob. Code § 3210 (b);
96. Colo. Rev. Stat. § 15-18.6-104 (3);
97. 16 Del. Code § 2510 (a) (4);
98. Idaho Code § 49-4504 (g);
99. Ind. Code § 16-36-3-3;
100. Miss. Code § 41-41-7;
101. Mo. Rev. Stat. § 27-431.063;
102. N. C. Gen. Stat. Ann § 90-21.13 (d);
103. N. Y. Pub. Health Code § 2994-q (2);
104. S. C. Code § 44-66-40 (A) ("Health care may be provided without consent to a patient who is unable to consent if no person authorized⋯ is available immediately, and in the reasonable medical judgment of the attending physician or other health care professional responsible for the care of the patient, the delay occasioned by attempting to locate an authorized person, or by continuing to attempt to locate an authorized person, presents a substantial risk of death, serious permanent disfigurement, or loss or impairment of the functioning of a bodily member or organ, or other serious threat to the health of the patient.").
105. Ga. Code § 31-9-3 (a).
106. Restatement (Second) Torts § 892D;
107. Stewart-Graves v. Vaughn, 170 P.3d 1151 (Wash. 2007);
108. Miller v. HCA, Inc., 118 S. W.3d 758 (Tex. 2003).
109. Mo. H. B. 392 § 191.1304, 96th Gen. Assembly (2011) (White).
110. E.g. Ga. Code § 31-9-3 (b) ("In addition to any instances in which a consent is excused or implied, at law, a consent to surgical or medical treatment or procedures suggested, recommended, prescribed, or directed by a duly licensed physician will be implied where an emergency exists."].
111. C. P. Sabatino, "The Evolution of Health Care Advance Planning Law and Policy", Milbank Quarterly 88, no. 2(2010):211-39.
112. Some states, like Delaware, also have comparatively shorter lists of eligible relatives. 16 Del. Code § 2507. In contrast, other states include, near the bottom of the list, 2 "nearest living relative" or "close adult relative"
113. E.g. D. C. Code § 21-2210;
114. Fla. Stat. Ann. § 765.401. The shorter the list, the more likely patients will be unbefriended.
115. Alaska Stat § 13.52.030 (d);
116. Ariz. Stat. § 36-3231 (A) (6)
117. Colo. Rev. Stat. § 19a-571;
118. D. C. Code § 21-2210;
119. Fla. Stat. § 765.401 (g);
120. Ga. Code § 31-9-2 (7);
121. Haw. Rev. Stat. § 327E-2;
122. Idaho Code § 39-4503;
123. 755 Ill. Cons. Stat. § 40/25 (a) (7);
124. A Me. Rev. Stat. § 5-805;
125. Md. Health-Gen. Code Ann. 5-605 (a) (2);
126. Miss. Code Ann. 41-41-203;
127. N. M. Stat. Ann. 24-7A-5;
128. N. Y. Pub. Health Code § 2994-d (l) (f)
129. N. C. Gen. Stat. § 90-322;
130. N. C. Gen. Stat. § 90-21. 13 (c) (7);
131. N. D. Cent. Code § 23-12-13;
132. Ore. Rev. Stat. § 127.635 (2) (g);
133. 20 Pa. Stat. Ann. § 5461;
134. S. D. Codified Laws § 34-12C-1;
135. Tenn. Code Ann. § 68-11-1806 (c) (3);
136. Utah Code Ann. § 75-2-108;
137. Va. Code § 54.1-2986 (A) (7);
138. W. Va. Code Ann. § 16-30-8;
139. Wisc. Stat. Ann. § 50.06;
140. Wyo. Stat. § 35-22-406. Delaware includes "close friend", but only if appointed as guardian.
141. 16 Del. Code § 2507.
142. N. M. Stat. § 24-7A-5 (c) However, the statute further dictates that a surrogate "may not be an owner, operator or employee of a health-care institution at which the patient is receiving care"
143. N. M. Stat. § 24-7A-5 (j).
144. 20 Pa. Cons. Stat. Ann. § 5461.
145. 38 C. F. R. § 17.32 (e) (4);
146. "Informed Consent for Clinical Treatments and Procedures", VHA Handbooks 1004. 01(14), 14 August 2009, http://www.va. gov/vhapublications/ ViewPublication.asp?pub-ID=2055, accessed 27 January 2012.
147. Ga. S. B. 367 (2009)
148. codified at Ga. Code Ann. § 31-9-2 (a) (7).
149. N. Y. Pub. Health Code § 2994-d (l) (f). Like most state statutes, this act contains certain restrictions on who may serve as a surrogate, even if the individual would otherwise qualify as a close friend. In particular, healthcare providers typically cannot qualify as close friends.
150. N. Y. Pub. Health Code § 2994-a (4).
151. N. J. A. B. 4098, 214th Legis. (2011) (Conaway). The bill was reintroduced in the next legislative session.
152. N. J. A. B. 1835, 215th Legis. (2012) (Conaway).
153. Barbee v. Kindred Healthcare Operating Inc., No. W2007-00517-COA-R3-CV (Tenn. App. 20 Oct. 2008).
154. Tenn. Code Ann. § 68-11-1806 (c).
155. The Tennessee Department of Health provides an "Appointment of Surrogate Form", http://health.state.tn.us/AdvanceDirectives/Surrogate.pdf, accessed 10 February 2012.
156. Tenn. Code Ann. § 68-11-1806 (c) (2).
157. Tenn. Code Ann. § 68-11-1806 (c) (3).
158. W. Va. Code § 16-30-8 (b).
159. The West Virginia Center for End-of-Life Care has developed a useful "Checklist for Surrogate Selection", http://www.wven doflife.org/MediaLibraries/WVCEOLC/Media/public/Surrogate-Selection-with- demographicinfo.pdf, accessed 10 February 2012.
160. Colo. Rev. Stat. § 15-18.5-103;
161. Haw. Rev. Stat. § 327E-5 (c) - (d). A 2006 roundtable meeting of the Elder Law Section of the Colorado Bar addressed that this statute needs to be amended to provide for an isolated individual with no close family or friends. Elder Law Section of the CBA, Meeting Minutes, 19 January 2006, http://www.cobar.org/repository/Inside-Bar/Elder/01.19.06%20min..pdf?ID= 2157, accessed 27 January 2012.
162. Colo. Rev. Stat. § 15-18.5-103 (6)
163. 16 Del. Code § 2507 (b) (3).
164. ABA Commission on Law and Aging, "Default Surrogate Consent Statutes", http://www.americanbar.org/content/dam/aba/migrated/aging/ PublicDocuments/famcon-2009.authcheckdam.pdf, accessed 27 January 2012.
165. E.g. N. M. Stat. § 24-7-A-5 (c);
166. N. Y. Pub. Health Code § 2994-d (2) ("An operator, administrator, or employee of a hospital or a mental hygiene facility from which the patient was transferred, or a physician who has privileges at the hospital or a health care provider under contract with the hospital may not serve as the surrogate for any adult who is a patient of such hospital, unless such individual is related to the patient by blood, marriage, domestic partnership, or adoption, or is a close friend of the patient whose friendship with the patient preceded the patient's admission to the facility.").
167. D. Meier, "Editorial-Voiceless and Vulnerable: Dementia Patients without Surrogates in an Era of Capitation", Journal of the American Geriatrics Society 45, no. 3(1997):375-77.