When capacity is uncertain, what should guide decision-making about treatment preferences?

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When capacity is uncertain, decisions about treatment should be guided by what the patient would have wanted, based on their known values and any previously expressed preferences or advance directives. This approach honors autonomy by aligning care with the person’s own wishes, even if they can’t voices them in the moment. If there is a documented directive or clear statements about values, those guide the choices. If no directive exists, clinicians and surrogate decision-makers should use substituted judgment, aiming to reflect the patient’s likely preferences, or, if that isn’t possible, act in the patient’s best interests. Input from family can inform the process, but it should not override the patient’s known wishes. Personal beliefs of the clinician and rigid institutional policies should not determine care when they conflict with the patient’s values.