AGS Sets Sights on Better Care, More Responsive Policies for “Unbefriended” Older Adults

Experts at the American Geriatrics Society (AGS) have unveiled new guidance on care and decision making for a unique and growing group of older adults: the “unbefriended.” Proposed clinical practice and public policy changes would support some of society’s most vulnerable individuals while also helping protect more of us from becoming unbefriended as we age.

The unbefriended lack the capacity to provide informed consent to medical treatment, often due to declines in physical and/or mental well-being.¹ But these individuals face added challenges because they have no written outline of their care preferences and also have no identified surrogate, such as a family member or friend, to assist in medical decision-making.¹ In long-term care settings, as many as 4% of residents could be classified as unbefriended.² Some studies also suggest that a large majority of older adults nearing end of life face serious medical decisions while also lacking decisional capacity—and potentially surrogates.³

“Health professionals have a special responsibility for the unbefriended, but we also face particularly challenging situations when it comes to their medical decisions,” notes Timothy W Farrell, MD, AGSF, a member of the expert panel responsible for the position statement. 

Across clinical practice, AGS experts have called for:¹

• Avoiding ad hoc approaches to decision-making to ensure fairness and respect;
• Identifying “nontraditional” surrogates—such as close friends, neighbors, or others who know a person well—wherever and whenever possible;
• Putting mechanisms in place to assess decision-making capacity in a systematic fashion;
• Standardizing approaches to caring for the unbefriended in urgent, life-threatening situations;
• Ensuring access to decision-making surrogates who are familiar, not only with a person’s medical condition, but also with his or her needs, preferences, and expectations; and
• Remaining sensitive to all available information—including cultural factors—when considering an unbefriended person’s best interests.

At a systemic level, AGS experts also recommend:¹

• Bringing national stakeholders together to create model legal standards that could be adopted by all states;
• Working with clinicians, health care organizations, and other stakeholders to prevent older adults from becoming unbefriended; and
• Developing innovative, efficient, and accessible approaches to protect decision-making for the unbefriended.

As an update to their earlier guidance released in 1996,⁴ the AGS Ethics Committee developed these new recommendations in collaboration with the AGS Clinical Practice and Models of Care Committee and the AGS Public Policy Committee. The final position statement was published online ahead of print in the Journal of the American Geriatrics Society, and is available for free from GeriatricsCareOnline.org. 

1. Farrell TW, Widera E, Rosenberg L, et al. AGS position statement: making medical treatment decisions for unbefriended older adults. J Am Geriatr Soc. [Published online November 22, 2016.]doi:10.1111/jgs.14586.

2. Karp N, Wood E. Incapacitated and Alone: Healthcare decision making for unbefriended older People. Human Rights. 2004;31(2). https://www.americanbar.org/publications/human_rights_magazine_home/human_rights_vol31_2004/spring2004/hr_spring04_incapacitated.html. Accesed November 9, 2016, from 

3. Silveria MJ, Kim SYH, Langa KM. Advance directives and outcomes of surrogate decision making before death. N Engl J Med. 2010;362(13):1211-1218. 

4. AGS Ethics Committee. Making treatment decisions for incapacitated older adults without advance directives. J Am Geriatr Soc. 1996;44(8):986-987.