How to Choose a Healthcare Proxy: The Person Who Speaks When You Can't

Why does choosing a healthcare proxy matter so much?

Susan Block was driving across the Bay Bridge in San Francisco. She had just left her father's hospital room. His surgery was the next morning.

Her father, Jack Block, was 74. A growth had appeared in the spinal cord in his neck. The operation had a 20% chance of leaving him paralysed from the neck down. Without it, paralysis was certain.

He had named her as his healthcare proxy. She was also an expert: a palliative care doctor known for training other doctors to talk about the end of life. Halfway across the bridge, she realised: "I don't know what he really wants."

So she turned the car around.

Going back "was really uncomfortable," she said. She asked him how much he would go through for a chance to stay alive. His answer shocked her. If he could still eat chocolate ice cream and watch football on TV, he wanted to live. He would accept a lot of pain for that.

She could not remember him ever watching a football game. "It wasn't the guy I thought I knew," she said.

After the operation, he started bleeding into his spinal cord. The surgeons needed to operate again to save his life. He would be badly disabled, perhaps for good. What did she want?

"I had three minutes to make this decision, and, I realized, he had already made the decision." — Dr Susan Block, in Atul Gawande's "Letting Go", The New Yorker, 2010

She asked the surgeons one question: would he still be able to eat ice cream and watch football? They said yes. So she said yes too.

He lived ten more years. He needed carers to wash and dress him, but his mind stayed sharp. He wrote two more books.

Without that talk, she said, her instinct would have been to let him go. Then she would have asked herself, "Did I let him go too soon?" Instead, "there was no decision for me to make."

That is the real gift of a good proxy. Not a name on a form, but a person who already knows your answer.

Her story is not rare. In a US study of 3,746 people aged 60 or older who died, 42.5% needed a major medical decision near the end. Of those, 70% could not make it themselves (Silveira et al., NEJM 2010). Yet only about 1 in 3 US adults has any kind of advance directive (Yadav et al., Health Affairs 2017).

What is a healthcare proxy, and what can they decide?

A healthcare proxy is the person who makes medical decisions for you when you cannot. Other names for the person are healthcare agent, surrogate or attorney-in-fact (in England and Wales, health and welfare attorney). The document that names them may be called a healthcare proxy form, a medical power of attorney or a durable power of attorney for health care. Our patient rights and planning guide explains how a proxy fits with DNR orders and other papers.

Your proxy can agree to or refuse treatment, including surgery. They can choose a hospital, hospice or care home, and see your medical records. They can decide when to move from treatment to comfort care. And they speak up for your wishes when others disagree.

Their power starts only when you cannot decide, for example in a coma or with advanced dementia (New York State Department of Health). While you can still decide, you decide.

How is this different from a living will? A living will is a map. A proxy is a guide who knows you. A map shows only the roads someone drew in advance. Real illness often takes a road nobody drew. No form predicted the question the surgeons asked Susan Block. She could answer it because she knew her father.

Most people are best protected by having both. Our guide on how to write a living will covers the map.

One limit is important. A proxy cannot ask for an assisted death for you. In US states with these laws, only the patient can make the request, and it cannot be written into an advance directive (Death with Dignity).

What happens if you do not name anyone?

The law often chooses for you. Every US state lets you appoint an agent. Most also set an order of relatives who decide when no one was named (JAAPL, 2022). The order often starts with a spouse, then adult children, then parents. When relatives disagree, some states use majority vote. In Tennessee and West Virginia, the doctor can decide.

Now picture your own family. Is your legal next of kin the person who knows your wishes best? A spouse you no longer live with? Three adult children who would vote? The Terri Schiavo case shows how hard it gets when a husband and parents disagree.

Malaysia has no specific law on mental capacity or on who makes health decisions for you (Tan, 2024). The government said in 2024 it was studying a Mental Capacity Act (The Star). In February 2026, the Malaysian Bar held a public talk on why the country still needs one (Malaysian Bar). For now, families and doctors decide together, without clear legal rules.

What makes a good healthcare proxy?

The best proxy is not always the person who loves you most. It is the person who can speak for you clearly on the worst day. Look for five things.

1. They know your values. Not just "no machines", but what makes your life worth living. Your faith. The conditions you would find unacceptable.
2. They will follow your wishes, even when they disagree. This is the hardest test. A daughter who wants "everything done" must still be able to say, "Mum did not want this."
3. They stay steady under pressure. Doctors may talk fast. Brothers and sisters may push. Your proxy must ask hard questions and keep calm.
4. They can be reached. They live nearby or can travel quickly, and they answer the phone.
5. They said yes freely. Never assume. A proxy who felt trapped will struggle when it counts.

Ask yourself: who could disagree with your choice, and still tell the doctor, "This is what they wanted"?

Should your proxy be your spouse, your child or a friend?

Each choice has a strength and a risk. A spouse or partner knows you best, but may be too close to let go. An adult child may understand you, but their brothers and sisters may fight the choice. A close friend is often calmer than family.

Some people are a poor fit, however much you love them. Think twice about someone who cannot say no to doctors or family. Or someone who would put their own beliefs before yours, who is in poor health, or who is in serious conflict with the rest of your family.

Your own doctor is often ruled out by law. Many states do not allow the doctor in charge of your care to act as your agent. In California, this applies even if that doctor is a relative (California Probate Code § 4659).

How do you ask someone to be your healthcare proxy?

Ask in a calm moment, not in a hospital corridor. Explain what the role involves. Give them real permission to say no. A "no" now is better than a "yes" they cannot keep later.

These five questions can open the talk:

1. "Are you comfortable making life-and-death decisions?"
2. "Can you speak up for my wishes even if others disagree?"
3. "How do you feel about my end-of-life wishes?"
4. "Will you be able to let me go, if that is what I want?"
5. "Do you understand what quality of life means to me?"

Watch how they answer. Hesitation is useful information. Thank them either way.

Then name a backup, also called an alternate proxy. Your first choice may be ill or abroad on the day it matters.

What should you tell your proxy so they can really decide for you?

This is the step most people skip. In a review of 16 studies with nearly 2,600 patient–surrogate pairs, surrogates guessed the patient's treatment wishes correctly only 68% of the time. They were wrong in about 1 case in 3 (Shalowitz et al., 2006). Being chosen by the patient did not make them more accurate. Neither did having talked about treatment wishes before.

The review does not say why. One possible reason is that most of these talks stay general. "I don't want to be kept alive on machines" sounds clear, but it is not. Which machines? For how long? With what chance of recovery?

Ellen Goodman, a journalist who won the Pulitzer Prize in 1980, learned this with her mother:

"We talked about everything except one thing: how she wanted to live at the end of her life." — Ellen Goodman, co-founder of The Conversation Project

When her mother could no longer decide, the decisions fell to Goodman. She faced them, she wrote, "wholly unprepared." She later co-founded The Conversation Project to help families talk.

The weight on the proxy is real. In a review of 40 studies, at least a third of surrogates felt a heavy emotional burden, often for months or years. The most common feelings were stress, guilt and doubt. Knowing what the patient wanted was often named as something that made it lighter (Wendler and Rid, 2011).

So be specific. Find your own "chocolate ice cream." Talk through these questions:

• What makes a day worth living for you?
• What abilities matter so much that you could not imagine living without them?
• How much pain or hardship would you accept for a chance at more time?
• When would you want to move from treatment to comfort care?
• What role does your faith play in these decisions?

Write the answers down. Say them out loud to your proxy. Then ask them to say them back to you in their own words. If they cannot, keep talking. Our guide on how to talk to family about end-of-life wishes can help you begin.

How do you make your healthcare proxy legal?

The rules depend on where you live.

In the United States, each state has its own form and its own rules for witnesses or a notary. You can download your state's free form from CaringInfo. New York, for example, uses a form called the Health Care Proxy. Its health department suggests giving copies to your agent, your doctor and family, and keeping one in your wallet (NY DOH).

In England and Wales, you make a health and welfare lasting power of attorney (LPA). It can cover daily care, medical care, moving into a care home and life-sustaining treatment. It can only be used when you cannot make your own decisions. You must register it with the Office of the Public Guardian. Registration costs £92, or £184 if you also make a property and financial affairs LPA. You may get a reduction if you earn under £12,000 a year (GOV.UK). You can cancel an LPA later if you change your mind (GOV.UK).

In Malaysia, no form makes a proxy legally binding yet. You can still write a signed letter that names the person you trust and lists your wishes. Give it to that person, your family and your doctor. It may not bind anyone in law, but it gives them your voice.

What should you do after you choose?

Give copies to your proxy, your backup and your doctor. Ask your doctor to put the form in your medical record. Look at it again after big life events, such as a new diagnosis, a divorce or a move. The free end-of-life readiness check shows what else your family might still need to know.

Susan Block turned her car around because a name on a form was not enough. You do not need to wait for the night before surgery.

Who would you trust with your voice? Does that person know your answer yet?

One small step for this week: invite them for coffee. Tell them about your own "chocolate ice cream", the thing that makes life worth living for you. The legal form can come next.