{'fraction_non_alphanumeric': 0.02147099132023755, 'fraction_numerical': 0.0045682960255824575, 'mean_word_length': 5.498516320474778, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Ethical challenge: when clinicians act as surrogates for unrepresented patients.

Many hospitalized patients require a surrogate decision maker because they are too ill to participate in decisions about their medical care. However, some patients do not have anyone available to serve as their surrogate. These “unrepresented patients” are vulnerable by virtue of their incapacity and the absence of a loved one to speak for them. They often come from historically marginalized populations, such as the homeless, those with mental illness or substance abuse problems, and the socially isolated elderly. When unrepresented patients develop advanced illness, clinicians face ethical challenges regarding when, if ever, it is permissible to forego treatments that could conceivably extend life. Difficulties in making end-of-life decisions for unrepresented patients have been documented in skilled-nursing facilities, general hospital wards, and intensive care units (ICUs). One-third of physicians who care for critically ill patients have acknowledged withdrawing life support in at least 1 patient who lacked decision-making capacity, a surrogate, and an advance directive. Approximately 1 in 20 deaths in ICUs occur in incapacitated patients without surrogates. Although numerous approaches to decision making for unrepresented patients have been proposed during the last 2 decades—including ethics committee oversight, appointment of a hospitalbased patient advocate as surrogate, or use of a lay member of an ethics committee—the dominant approach remains the “clinicians as decision maker” model. For example, in a recent multicenter study, 81% of life support decisions for unrepresented patients were made by the treating clinical team alone or in consultation with another attending physician. Hospital-level oversight of the decisions occurred in fewer than 20% of cases. There are 6 main ethical concerns that arise when clinicians serve as both the clinician and surrogate for a patient. We argue that treating clinicians have an important role to play in decision making for unrepresented patients, but they should not have sole decisional authority over life support decisions.