Many hospitalized patients require a surrogate decision maker because they are too ill to participate in decisions about their medical care.1,2,3  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,5,6  general hospital wards, and intensive care units (ICUs).8–10  One-third of physicians who...

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