Choosing a healthcare proxy, and what you are asking of them

A healthcare proxy — the terminology varies, and the role is broadly the same — is a person authorised to make medical decisions for you if you cannot make them yourself.

Most people appoint their spouse, or their eldest child, on the basis of relationship. That is understandable and it is frequently not the best choice.

What the job actually involves

Being telephoned at three in the morning. Being asked, by a doctor, whether to continue treatment. Sitting in a room while a consultant explains a prognosis. Saying no to something that other family members want.

And then living with it.

The proxies who struggled most, in my experience, were the ones who loved the person most and could not separate what they wanted from what the person would have wanted.

The ones who did best were the ones who could hold a position under pressure and who had been told clearly, in advance, what was wanted.

What to look for

Someone who can make a decision under stress. Some people freeze, and that is not a character flaw. It does make them a poor choice for this.

Someone who will follow your wishes rather than their own. This is the crucial quality. The proxy's job is to represent what you would have decided, not what they would decide, and not what they wish for you.

Ask directly: "If I told you I would not want to be kept alive in a particular situation, could you tell a doctor to stop, even if you did not agree?" The answer matters.

Someone who can be present. Geography and availability are practical constraints. Someone in another time zone with a demanding job may not be able to be there.

Someone who can handle family conflict. The proxy will frequently be dealing with relatives who disagree, and needs to be able to say that the decision is theirs to make.

Someone who will actually accept. Ask them. Appointing someone without asking is common and it is unfair.

What not to weight too heavily

Closeness. The person you love most may be the person least able to authorise stopping treatment.

Seniority. The eldest child is a convention rather than a qualification, and it produces resentment among siblings who feel better suited.

Medical knowledge. Useful and secondary. The doctors provide the medical information; the proxy provides knowledge of you.

Avoiding offence. Choosing someone to avoid upsetting them is a poor basis for a decision of this weight. The offence caused by explaining your reasoning is smaller than the harm caused by appointing the wrong person.

Name a substitute

Your first choice may be unavailable, may be unwell themselves, may predecease you, or may be involved in the same accident.

Name at least one alternate. Some people name two.

Avoid appointing two people jointly with equal authority unless you are confident they agree, since a deadlock in an emergency is exactly what you were trying to prevent.

Then have the conversation

This is the part that makes the appointment work, and it is the part most often skipped.

The document gives them authority. The conversation gives them the information to use it.

What to cover:

What matters to you about quality of life. What you would find unacceptable. What you are frightened of. Whether there are circumstances in which you would want treatment stopped. Whether there is anything you would want regardless. Your views on being cared for at home versus in hospital. Anything religious or cultural that matters.

Then, and this is the sentence that helps most: tell them explicitly that if they have to make a difficult decision, you trust them, and that you will not have wanted them to carry guilt about it.

Proxies carry that guilt for years. Being told in advance that the decision was authorised, and that the person making it was trusted, is a genuine gift.

Practical steps after appointing

Give them a copy of the document and of any written directive.

Give a copy to your doctor and ask for it to be recorded.

Tell the rest of the family who you have appointed and why, so that nobody is surprised at the worst moment. Family conflict at a bedside is frequently about a proxy nobody knew about.

Review periodically. Relationships change, people move, and the person who was right ten years ago may not be now.

If you have nobody

Some people have no obvious candidate.

Options depend on jurisdiction and may include appointing a friend, a professional, or in some systems relying on statutory arrangements where a court or an appointed representative decides.

Where there is genuinely nobody, a detailed written directive matters more, because it is the only voice you will have.

It is worth raising this specifically with your doctor, since arrangements exist and they vary.

This is general information. The available documents, their names and their legal effect differ by jurisdiction. Discuss with your doctor and, where appropriate, a qualified legal adviser.