Making (Medical) Decisions for Others: Back-Up Decision-Makers (BUDs) for Incapacitated Loved Ones and Friends

Imagine this scenario: Jane, a relative or close friend you haven’t seen in a while, texts you, “I’m hungry and it’s dinnertime! Takeout at your house at 7?” When you ask what to order for her, she replies, “I can’t decide. You know me and what I like — you decide. See you at your house at 7!” Then she puts her phone on Do Not Disturb. 

How do you feel about that? You might feel flattered that Jane trusts your judgment, but also frustrated because you don’t know her current dietary preferences or how hungry she is. You try to imagine what Jane would want based on past meals. The last time you ate together, she had a vegan dish she didn’t like. Before that, she was on a keto diet and didn’t enjoy that meal either. These experiences may tell you what not to order but they don’t clearly guide you on what Jane would prefer now. You consider ordering two of whatever you’re having, but then remind yourself that Jane’s tastes might differ from yours. What to do?

Making choices for someone else, even about something as simple as dinner, can feel weighty. It’s hard to step into Jane’s shoes and make decisions about what she’ll eat, especially without knowing her current likes and dislikes. You might wish you could ask Jane questions to better understand her preferences, which would help you decide with more confidence.  

Now, imagine a different scenario. It’s dinnertime and your phone rings. A doctor or nurse from [Local] Hospital calls, saying, “I’m caring for Jane. She’s been admitted and is seriously ill and incapacitated, so she can’t make her own medical decisions. She named you as her decision-maker last time she was here. We need to discuss treatment options immediately.”

Suddenly, you’re thrust into a complex and emotional situation, asked to make decisions far more important than choosing dinner.  

Life is unpredictable. Illnesses and accidents can happen anytime. This is why all adults should have a Back-Up Decision-maker (BUD) — someone willing to make medical decisions on their behalf if they become incapacitated. If you’re part of a family or close circle of friends, one of them might call on you to be their BUD. If that happens, understanding what it means to be a BUD, and what you can do to prepare, can make a big difference in the experience for both you and the person you’re helping.  

How does a person become a BUD? People become BUDs in various ways: through a formal document such as a proxy directive, durable power of attorney, Practitioner Orders for Life-Sustaining Treatment (POLST), or hospital paperwork. If no one is named, hospital policies and local laws determine who can serve, usually prioritizing spouses or civil union partners, then adult children, parents, siblings, and other relatives.

Being named a BUD doesn’t mean you must serve. If you’re unwilling, the medical team will seek the next eligible person. If you do accept, you’ll collaborate with the care team as if you were the patient, which respects the patient’s autonomy.

The bioethical principle of respect for autonomy holds that in general, adults have the right to decide what medical treatments they will accept or refuse. If they’re incapacitated, this right doesn’t disappear; instead, it’s exercised by their BUD on their behalf.

Being a BUD is a serious responsibility. You must be reachable by phone and sometimes in person. You’ll need to understand the patient’s evolving condition and carefully consider treatment options. What seems straightforward — for example, accepting blood transfusions or ventilator support — can be complicated by the patient’s values and medical circumstances.

How should a BUD make medical decisions for the patient? There are two main ethical standards:

1. Substituted Judgment. If you know the patient’s values, wishes, and beliefs, you should make the decision the patient would make if the individual were able to make it. For example, if the patient would accept blood transfusions, you should consent — even if your own beliefs differ.
2. Best Medical Interests. If you don’t know the patient’s preferences and no one else can advise you, you decide based on what maximizes medical benefit and minimizes risks and burdens, with the help and support of the medical care team.

Being a BUD is a profound expression of compassion and respect. If you are or might be a BUD, it’s important to prepare by talking with the person about the individual’s values, wishes, and beliefs — especially regarding life-sustaining treatments and religious considerations. There are many helpful guides and workbooks to facilitate these conversations.

For more information about being a BUD, how to designate a BUD, or how to put your healthcare wishes in writing, consult the New Jersey Department of Health website: https://www.nj.gov/health/advancedirective/ad/what-is/.