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Adults who are incapacitated and alone, having no surrogates, may be known as ‘‘unbefriended.’’ Decision-making for these particularly vulnerable patients is a common and vexing concern for healthcare providers and hospital ethics committees. When all other avenues for resolving the need for surrogate decision-making fail, patients who are incapacitated and alone may be referred for ‘‘public guardianship’’ or guardianship of last resort. While an appropriate mechanism in theory, these programs are often under-staffed and under-funded, laying
the consequences of inadequacies on the healthcare system and the patient him or herself. We describe a qualitative study of professionals spanning clinical, court, and agency settings about the mechanisms for resolving surrogate consent for these patients and problems therein within the state of Massachusetts. Interviews found that all participants encountered adults who are incapacitated and without surrogates.

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