When the Patient Cannot Decide for Themselves

Shared-Decision Making in the Setting of Substituted Judgment

28 June 2026, 1:30 PM – 4:55 PM | 13:30 – 16:55 (local time)

Faculty

  • Kathleen Kieran, MD, MS, MME – Professor of Urology; Vice Chair of Urology; Fellowship Director for Pediatric Urology, Seattle Children’s Hospital, University of Washington, United States
  • Matthew L. Russell, MD, MSc – Instructor in Medicine, Massachusetts General Hospital, Harvard Medical School, United States

Course Overview

Divergent objectives and narratives between healthcare team members may lead to suffering and hinder alignment between patient care and the patient’s priorities and wishes. Substituted judgment—where another person (a proxy) makes healthcare decisions on behalf of the patient—can further complicate communication. This is particularly common in pediatric and geriatric populations, as well as among patients with cognitive impairment.

Research on shared decision-making in these settings has identified caregiver involvement, regulatory and policy considerations, and clinician communication skills as key factors influencing effectiveness. There is a clear need for training that equips clinicians to communicate effectively with both patients and proxies while ensuring that all perspectives are identified, heard, and understood.

This course focuses on developing the skills needed to partner with patients and proxies in complex decision-making contexts. While shared decision-making is often framed as a dyadic interaction between clinician and patient, this model may not fully address situations involving substituted judgment. The course emphasizes a relationship-centered approach that incorporates multiple stakeholders, acknowledges differing perspectives, and addresses uncertainty as a central component of decision making.

Participants will learn and practice techniques including relationship-centered communication and mind mapping to elicit and organize stakeholder perspectives. The course also explores how uncertainty is experienced differently across stakeholders and how it can be acknowledged and leveraged to support more effective and collaborative decision making.

Learning Objectives

Participants will learn how to:

  • Describe ways in which substituted judgment can alter the content and delivery of information between patients, proxies, and healthcare teams
  • Utilize relationship-centered communication skills to elicit stakeholder preferences and distinguish between patient and proxy perspectives
  • Describe clinical uncertainty and identify techniques to incorporate and leverage uncertainty in decision making
  • Use mind mapping to gather, organize, and integrate the perspectives of multiple stakeholders

Course Format

This course includes brief presentations, facilitated discussion, and interactive exercises.

Participants will engage in:

  • Guided discussions on substituted judgment and shared decision-making
  • Practice of relationship-centered communication skills in small groups
  • Hands-on exercises using mind mapping to organize stakeholder perspectives
  • Group reflection and discussion to reinforce learning and application

Participant Requirements

No prerequisites are required.