shift is wild

Orders, handoffs and other people

When someone else says yes for the patient

The surrogate said yes, with conditions. Here is how to chart it so the 4 a.m. nurse actually knows about them.

9 min read built on 6 full opinions updated 2026-10-01

Written by a med-surg RN, ten years, day shift. Why there is no name on it

Denise reacting to this topic
All 11 sections

Your patient is confused, sedated or not responding. A daughter, a husband or a health care agent is making the calls. They say yes to the antibiotic and no to the feeding tube, or fine, but call me before you intubate. Your note needs four things: who this person is, where their authority comes from, exactly what they agreed to or refused, and what the patient showed or said at the time.

The short version

  • Name the decision-maker and how they're related. Full name, relationship, phone number. Bedside or phone.
  • Say where the authority comes from. Health care POA or advance directive? Guardianship order? Default surrogate under your facility's policy? Note whether there's a copy in the chart, and where.
  • Write the exact treatment and every condition. Something like yes to the chest tube, no CPR, call me before any intubation. A condition that isn't in the note won't make it to the next shift.
  • Describe the patient in plain observations. What they said, what they did, how they answered orientation questions. Confused doesn't cut it.
  • Close the loop. Who you told (provider, charge nurse), when you tried to reach the surrogate, and what happened.

What to write instead

Who the person is

How it often gets charted Better
Consent from family.Consent obtained by phone from Maria Lopez, granddaughter, (555) 201-3344, at 1430.
Wife at bedside agrees.Spouse Linda Park present at bedside, identified self as health care agent.
Son ok with plan.Son James Reed reached at 0915. States he is not the named agent; agent is daughter Ann Reed. Charge RN notified. Message left for Ann Reed at (555) 410-2210.

Where the authority comes from

How it often gets charted Better
POA on file.Health care POA dated 11/12/2009 naming Maria Lopez as agent, copy in chart under Advance Directives tab, reviewed by this RN at 1430.
Family is decision maker.No health care POA or guardianship order located. Daughter acting as surrogate per facility policy. Social work notified to confirm.
Has AD.Agent states pt has advance directive at home; agent to bring copy. Not yet in chart as of 1500. Provider aware.

What exactly they agreed to or refused

How it often gets charted Better
Family consents to procedure.Agent consented to right chest thoracentesis after Dr. Joseph explained procedure by phone. Agent asked if intubation would be needed; Dr. Joseph stated no.
DNR, no heroics.Agent states: no CPR, no intubation without calling her first at (555) 201-3344. Instructions read back to agent and confirmed. Code status order checked: DNR. Charge RN informed. Added to handoff.
Family refused med.Agent declined haloperidol 2 mg IM after discussing reason (pulling at lines) with provider. Agent agreed to mitts and 1:1 sitter. Dr. Shah notified at 2210, order discontinued.
Pt refused, wife said give it.Pt pushed cup away x2 when offered PO lorazepam. Agent (wife) informed at bedside; wife asked to hold and try again in 1 hour. Med held, Dr. Shah notified 1840.

What the patient showed or said

How it often gets charted Better
Pt confused.Pt oriented to name only. States year is 1987, states she is at home. Unable to repeat back purpose of procedure after explanation x2.
Pt agitated, uncooperative.Pt pulled arm away during IV start, said no more needles, and tried to get out of bed. Unable to stand without assist.
Pt lacks capacity.Per Dr. Lee note at 0900, pt lacks decision-making capacity for this decision. RN observation at 1000: pt unable to state why she is in hospital.
Pt agrees.Pt nodded when asked if ok to give IV antibiotic; unable to say what the medication is for. Agent consent documented above.

Copy this

`` [DATE] [TIME] Decision-maker: [FULL NAME], [RELATIONSHIP TO PT], phone [NUMBER]. Contact: [IN PERSON AT BEDSIDE / BY PHONE]. Authority: [HEALTH CARE POA / ADVANCE DIRECTIVE / GUARDIANSHIP ORDER / DEFAULT SURROGATE PER FACILITY POLICY], dated [DATE OF DOCUMENT]. Copy [IN CHART UNDER [TAB OR SECTION] / NOT IN CHART - REQUESTED]. Reviewed by [NAME, CREDENTIAL] at [TIME]. Pt status at time of decision: [ORIENTATION ANSWERS, WHAT PT SAID, WHAT PT DID]. Capacity determination: [PROVIDER NAME, TIME OF NOTE / NONE DOCUMENTED - PROVIDER NOTIFIED]. Treatment discussed: [EXACT MED, DOSE, ROUTE OR PROCEDURE]. Explained by [NAME, CREDENTIAL], including [KEY POINTS COVERED, E.G. NEED FOR INTUBATION / SEDATION / RISKS]. Decision-maker response: consented to [EXACT TREATMENT]. Conditions or limits stated: [E.G. NO CPR; CALL AGENT BEFORE ANY INTUBATION AT [NUMBER]; NONE STATED]. Limits read back to decision-maker and confirmed: [YES / NO]. Notified: [PROVIDER NAME] at [TIME]; charge RN [NAME] at [TIME]. Code status order checked: [CURRENT ORDER]. Limits added to handoff report. [YOUR NAME, CREDENTIAL] ``

Chart note: surrogate declines a med or treatment

`` [DATE] [TIME] Decision-maker: [FULL NAME], [RELATIONSHIP TO PT], phone [NUMBER], [IN PERSON / BY PHONE]. Authority: [DOCUMENT TYPE AND DATE / DEFAULT SURROGATE PER FACILITY POLICY], location in chart: [WHERE]. Pt status: [WHAT PT SAID AND DID, ORIENTATION ANSWERS]. Ordered treatment: [MED, DOSE, ROUTE / PROCEDURE], ordered by [PROVIDER] for [REASON GIVEN IN ORDER]. Information given to decision-maker: [WHAT WAS EXPLAINED AND BY WHOM]. Decision-maker declined [EXACT TREATMENT]. Reason given by decision-maker: [THEIR STATED REASON, PARAPHRASED]. Alternatives discussed: [E.G. MITTS, SITTER, PO INSTEAD OF IM / NONE]. Treatment held at [TIME]. [PROVIDER NAME] notified at [TIME]. Provider response: [ORDER DISCONTINUED / NEW ORDER / PROVIDER TO SPEAK WITH DECISION-MAKER AT [TIME]]. [YOUR NAME, CREDENTIAL] ``

Chart note: surrogate's condition applies and they can't be reached

`` [DATE] [TIME] Pt condition change: [VITALS, RESP STATUS, WHAT YOU OBSERVED]. Standing instruction from decision-maker [FULL NAME, RELATIONSHIP]: [EXACT INSTRUCTION, E.G. CALL BEFORE ANY INTUBATION], documented [WHERE AND WHEN]. Call attempts to decision-maker: [TIME] to [NUMBER] - [NO ANSWER / VOICEMAIL LEFT / REACHED]. [TIME] to [SECOND NUMBER] - [RESULT]. [PROVIDER NAME] notified at [TIME] of condition change and of decision-maker instruction. Provider response: [WHAT PROVIDER ORDERED OR SAID]. Charge RN [NAME] notified at [TIME]. [HOUSE SUPERVISOR / CHAIN OF COMMAND] notified at [TIME]: [NAME]. Action taken: [WHAT WAS DONE, BY WHOM, AT WHAT TIME]. Decision-maker informed at [TIME] by [NAME] of [WHAT WAS DONE]. [YOUR NAME, CREDENTIAL] ``

Message to charge nurse or supervisor

`` [DATE] [TIME] Pt: [ROOM], [PT IDENTIFIER PER POLICY]. Decision-maker: [FULL NAME], [RELATIONSHIP], authority via [DOCUMENT TYPE / DEFAULT SURROGATE]. Issue: [E.G. AGENT INSTRUCTION TO CALL BEFORE INTUBATION; PROVIDER ORDERED INTUBATION; AGENT NOT REACHED AFTER [NUMBER] ATTEMPTS] / [E.G. AD NOT FOUND IN CHART] / [E.G. TWO FAMILY MEMBERS GIVING CONFLICTING INSTRUCTIONS]. What I have done: [CALLS, NOTIFICATIONS, TIMES]. What I need: [E.G. GUIDANCE ON NEXT STEP / HELP LOCATING DOCUMENT / SOCIAL WORK OR ETHICS CONSULT]. [YOUR NAME, CREDENTIAL, CONTACT] ``

Words that do the damage

Word or phrase Why it hurts Use instead
familyDoesn't say which person or whether they hold authorityFull name, relationship, and the source of authority
POA on fileDoesn't say what kind of POA, whether it covers health care, or where it isDocument type, date, agent's name, where filed, who reviewed it
consent obtainedDoesn't say who, for what, after what explanationTreatment named, who explained it, who agreed, time, phone or in person
no heroicsMeans something different to every readerThe specific interventions: no CPR, no intubation, call agent first
pt confused / lacks capacityA conclusion, not something you observedOrientation answers, what the pt said and did
agreeable / cooperativeHides whether the pt actually understoodWhat the pt did (nodded, held out arm) and what they could not explain
family awareDoesn't say who was told, what, or whenName, time, how they were reached, what was said

If you remember one thing

Who decided. On what authority. Exactly what they agreed to or refused, limits included. And what the patient showed you at the time.

What goes wrong

The classic is a note that says consent was obtained and stops there: Consent obtained from family. On the day, it looks fine. Months later nobody can tell from it:

  • Who gave consent. Which family member? The agent named in the document, or a cousin who happened to be in the room?
  • For what. The thoracentesis? Or the thoracentesis plus the intubation that came with general anesthesia?
  • On what conditions. Yes to everything, or yes with a limit?
  • Based on what. Did they hear what the procedure involves, or only part of it?

Then there's where the instructions end up. A surrogate's limits (no CPR, call me first) tend to land in a provider's progress note, or in a paper directive filed in the wrong spot. The nurse at 4 a.m. never sees them. So when a surrogate tells you something that limits care, put it in your note. Put it wherever your facility flags code status and directives. Say it at handoff.

And the patient's own voice drops out. A patient who can't consent can still pull away, say no more, or get two orientation questions right. If all the chart says is pt confused, it doesn't show why someone else was making the decisions.

What the guidance says

  • If the patient can still understand and express what they want, the patient decides. The agent steps in when they can't. (Illinois Legal Aid Online, Kelley Uustal)
  • An agent named in a medical power of attorney can say yes or no to specific treatments for the patient. Which ones depends on what the document grants. (FreeWill, Kelley Uustal)
  • No named agent and no court-appointed guardian? Then a family member or someone close to the patient may act as a default surrogate. The rules vary by state. (Vermont Ethics Network, Merck Manual)
  • Chart what you saw and heard. Not your interpretation of it. (ASRN, All Healthcare Careers)

It is not hypothetical

What happened in 5 court cases — tap to read

Doctors Hospital of Augusta v. Alicea (Supreme Court of Georgia, 2016). A 91-year-old woman's advance directive named her granddaughter as her health care agent. The granddaughter told the physicians no CPR, and to call her before any intubation. One physician charted it. At summary judgment the record has to be read in the family's favor, and read that way, the directive was in the chart but not where hospital policy said it should be. Around 4 a.m. the patient was intubated. Nobody called the agent. The court held that the hospital and the surgeon were not entitled to summary judgment on statutory immunity. One of the reasons was the hospital's own policy, which:

required the nursing staff to confirm the instructions in the Advance Directive and document this action during the initial assessment and to reconfirm the instructions and document this action on any transfer within the facility

https://www.courtlistener.com/opinion/3219802/doctors-hospital-of-augusta-v-alicea-admrx/

Doctors Hospital of Augusta, LLC v. Alicea (Court of Appeals of Georgia, 2015). Same case, one level down. The court let the medical battery claim over the March 7 intubation go forward. It reversed on the consent claims for the March 5 surgery. For that one, the agent had agreed by phone and nobody told her the surgery required intubation. About the night of the intubation, the court wrote:

Despite the notation in the progress notes that there was to be no CPR or intubation without calling Alicea, the nurses did not contact Alicea, who had gone home for the night.

The limit was charted. Nobody acted on it.

https://www.courtlistener.com/opinion/2810451/doctors-hospital-of-augusta-llc-et-al-v-alicea/

Martha Mourning, FNP and Kharvar Dar, MD v. George Muns (Texas Court of Appeals, Eastland, 2024). A patient self-extubated. A nurse called his medical power of attorney to update her, and a few minutes later he was reintubated. On appeal the only question was whether the patient's expert reports were adequate. The court reversed the denial of the providers' motion to dismiss and sent the case back. So this is not a finding that anyone did anything wrong. Still, describing the record, the court wrote:

However, there is no record that Bittick attempted to obtain consent for Muns to be reintubated.

A call to the POA that gives an update but documents no consent conversation leaves a gap. Someone else will fill it in later.

https://www.courtlistener.com/opinion/10161792/martha-mourning-fnp-and-kharvar-dar-md-v-george-muns/

Moriarity v. Rockford Health Systems, Inc. / In re Estate of Darlene Allen (Appellate Court of Illinois, 2006). One opinion, listed twice. A physician decided an ED patient wasn't competent to refuse, and blood and urine were taken over her objection. The trial court gave the defendants summary judgment. The appellate court reversed: there were real factual disputes over whether the emergency exception applied. In the court's words, the claim:

Plaintiff claims that defendants failed to obtain consent for the extraction either directly from Allen or indirectly from someone authorized to consent to the treatment for her.

A lot of the record came down to what the chart said about her behavior. She walked away. Her speech was slurred. Which orientation questions she answered, and when.

https://www.courtlistener.com/opinion/2224009/moriarity-v-rockford-health-systems-inc/ https://www.courtlistener.com/opinion/3143557/in-re-estate-of-darlene-allen/

Read the decisions yourself

Every case below is a published decision on CourtListener. Open them. Nothing on this page asks you to take our word for what a court said — and where we only had the search result rather than the full opinion, it says so.

All the decisions behind this guide, in one page — searchable by court, year, or what happened.

What people say on the floor

Nurses talking to each other about this, quoted as they wrote it. This is opinion, not a source. It is here because it shows what the argument actually is — the rules above come from the decisions and the published guidance, not from these threads.

  • Confused people, depending on the level of confusion, likely do not have capacity to either consent to or refuse medical treatment. Their POA or next of kin needs to be contacted to get consent.

    r/nursing on Reddit: Confused patients rights reddit

  • A person who is determined by psyc ... + unable to reach family/not enough time to without the person dying, informed consent is implied technically....

    r/nursing on Reddit: Right to refuse? reddit

  • If there is a power of attorney at play then they are considered to be acting on behalf of the patient so they can withdraw consent as if they were the patient. It's a ridiculous loophole but it exists.

    r/nursing on Reddit: What happens if a patient’s spouse wants to change from DNR to Full C reddit

  • I have had a&ox4 patients sign it in the morning when I’m waking them for med pass anyway, but if I have no other reason to wake them up or if I know they still have questions or I need to call POA for consent I just hold off on the witness part and pass it on to dayshift.

    r/nursing on Reddit: Signing consents reddit

What everyone else says

Guidance from professional bodies, insurers and other people who write about this. Useful, but it is advice, not law — that part is above.

How would you chart it?

This is the part we cannot research. If you have a way of writing this that has held up — put it here. No account, no name needed. Nothing that could identify a patient: no room numbers, no dates of birth, no MRNs. Use placeholders, the example still works.

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