Facing death is rarely easy. As dying becomes an imminent reality rather than a remote inevitability, patients often have difficulty choosing among treatment alternatives, even if they are cognitively intact. Health care proxies, when confronting options ranging from burdensome, invasive treatment to exclusively palliative care, frequently are uncertain about what to select. Legally appointed guardians, particularly when they are designated to speak for someone with whom they have had no prior relationship, have little on which to base end-of-life decisions. Providing guidance to each of these groups is essential if medical decision making is to reflect the patient’s values and goals. As Cohen et al1 point out in a provocative article in this issue of JAMA Internal Medicine, public guardians making decisions for unbefriended older people are in greatest need of guidance on what kind of and how much medical care to choose.
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