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Published On May 24, 2016

POLICY

Defined: Unbefriended

Every incapacitated patient needs someone to help make medical decisions on their behalf. But some lack any friends or family members who could help.

unbefriended (adj.): Patients who lack the capacity to make their own medical decisions but who have no family members or other surrogates to speak on their behalf.

When an incapacitated patient needs help, most states will authorize someone—a spouse, a parent, an adult child or a grandchild, or sometimes even close friends—to make important health care decisions on that person’s behalf. But what about patients who have no one? Medical literature calls them the “unbefriended.”

Unbefriended patients are mostly elderly, with many suffering from dementia or mental illness. Some have alienated their families, while others have simply outlived them. Looking at the rising number of childless and unmarried Americans over age 65, one recent case study estimates that as many as 22% of seniors are at risk of becoming “elder orphans,” another term for the unbefriended elderly.

Treating this group poses an ethical riddle for hospitals and nursing homes. Medical care, especially at the end of life, should incorporate a patient’s wishes about aggressive life-saving treatments, hospice care and other crucial issues. The unbefriended leave those questions up to their caregivers. Many are living out their days receiving painful and life-prolonging treatments in long-term-care institutions—which may be contrary to their own unexpressed wishes.

A solution is sorely needed. In some cases, public guardians, such as qualified lawyers or social workers, can be appointed to make important decisions, although the legal process often takes a long time. Some nonprofits, such as the Vera Institute of Justice Guardianship Project in New York City, have been formed to offer guardianship for these patients. And a 2013 Perspective article in The New England Journal of Medicine suggests that hospital ethics committees might play a role in making decisions for these patients.

A report from the American Bar Association Commission on Law and Aging sets forth the problem in its starkest terms: The unbefriended are “voiceless and vulnerable…. [W]e owe it to them to help them to live better or to die in comfort and not alone.”