Clinicians are often called upon to assess the capacity of a patient to appoint a healthcare agent. Although a consensus has emerged that the standard for such assessment should differ from that for capacity to render specific healthcare decisions, exactly what standard should be employed remains unsettled and differs by jurisdiction. The current models in use draw heavily upon analogous methods used in clinical assessment, such as the “four skills” approach. This essay proposes an alternative model that relies upon categorization and sliding scale risk assessment that can be used to determine to how much scrutiny the proxy appointment should be subjected and how much certainty of accuracy should be required in order to maximize the patient’s autonomy and ensure that her underlying wishes are met.

An estimated 1 in 4 elderly Americans need a surrogate to make decisions at least once in their lives. With an aging population, that number is almost certainly going to increase. This paper focuses on financial surrogate decision making. To illustrate some of the empirical and moral implications associated with financial surrogate decision making, two experiments suggest that default choice settings can predictably influence some surrogate financial decision making. Experiment 1 suggested that when making hypothetical financial decisions, surrogates tended to stay with default settings (OR = 4.37, 95% CI 1.52, 12.48). Experiment 2 replicated and extended this finding suggesting that in a different context (OR = 2.27, 95% CI 1.1, 4.65). Experiment 2 also suggested that those who were more numerate were less likely to be influenced by default settings than the less numerate, but only when the decision is whether to “opt in” (p = .05). These data highlight the importance of a recent debate about “nudging.” Defaults are common methods to nudge people to make desirable choices while allowing the liberty to choose otherwise. Some of the ethics of using default settings to nudge surrogate decision makers are discussed.

Conservation planning often relies on measures such as species richness and abundance to prioritize areas for protection. Nonetheless, alternative metrics such as functional traits have recently been shown to be useful complementary measures for detecting biological change. Timely conservation planning often precludes the collection of such detailed biological data relying instead on remotely-sensed habitat mapping as a surrogate for diversity. While there is evidence that habitat maps may predict taxonomic species richness and diversity in some coastal ecosystems, it is unknown whether similar strong relationships exist for functional traits and functional multimetrics. We compared the performance of physical habitat structural complexity obtained from high definition swath mapping in explaining variation in traditional taxonomic metrics as well as functional traits (e.g., maximum length, trophic level, gregariousness) and functional multimetrics (e.g., functional richness, dispersion) of fish assemblages. Reef complexity measures were good surrogates for fish species richness and abundance but not for functional traits or multimetrics, except functional richness at the scale of 1 m. Remotely sensed habitat maps may not be a good surrogate for predicting functional traits and multimetrics of fish assemblages, and must be used with caution when maximizing such aspects of assemblages is a priority for conservation planning.

To determine potential surrogates of littoral macroinvertebrate communities for marine bioassessment and for evaluating biological conservation, the different taxonomic resolutions as surrogates were studied based on six datasets collected from intertidal zones of the Yellow Sea, near Qingdao, northern China, during the period of 1989–1998. Samples were collected yearly at five stations with different bottom types during the summer season (June). The genus- and family-level resolutions maintained sufficient information to analyse the ecological patterns of the macroinvertebrate communities for assessing ecological quality status in littoral ecosystems. The mollusc assemblages, alone or in combination with arthropod assemblages, may be used as a surrogate of littoral macroinvertebrate communities, at both species- and genus-level resolutions. The results suggest that the use of simplifications in macroinvertebrate fauna at genus-level resolutions or using smaller taxonomic assemblages (e.g. molluscs and arthropods) are time-efficient and would allow improving sampling strategies of large spatial/temporal scale bioassessment programmes and biological conservation researches in littoral ecosystems.

Background: Dementia differs from other terminal illnesses both in its slow progression and the fact that patients and family members often do not perceive it as a cause of death. Furthermore, because decisional incapacity is almost universal in patients with advanced dementia, decisions must be made by surrogates. However, little is known about the factors that influence how surrogates make decisions for persons with late-stage dementia.

Methods: The setting was the first wave of a study of patients with advanced dementia in three Maryland nursing homes (The Care of Nursing Home Residents with Advanced Dementia Study). Of 125 consented participants, 123 residents and their surrogates provided adequate information and agreed to interviews and medical record reviews. Bivariate analysis and logistic regression models were used to explore whether variables related to demographics, illness, communication and surrogate background were associated with surrogate decisions to not provide aggressive treatments (i.e. hospitalization or surgery).

Results: Treatment decisions regarding aggressive medical care had been made by 81% of surrogates over the preceding 6 months. In bivariate analysis the following factors were significantly associated with not providing aggressive care: resident and surrogate of white race, older surrogate age, worse resident medical illness, worse surrogate perception of resident quality of life, presence of a ‘do not hospitalize’ order (DNH), and more contact with nurses. In the multivariate analysis, resident white race and presence of a DNH were significant predictors of surrogate decisions to not provide aggressive treatments. Treatment decisions were not associated with surrogate relationship or religiosity.

Conclusions: Treatment decisions for individuals with advanced dementia are mostly strongly associated with the patient's race and presence of DNH and less so with changeable features of illness or environment.