When people cannot make decisions for themselves, guardians and conservators take on the very important job of making decisions for them. Acting as another person's substitute decision maker can be very rewarding. The guardian or conservator has to be careful that he or she is acting in the ward's best interest, not his or her own.

Are There Guidelines for Substitute Decision Making?
In making decisions for someone else, there are important factors to consider:

• Remember how you would like to be treated if someone was making decisions for you;
• Take actions and make decisions that encourage and allow the maximum level of independent activities of the ward;
• Exercise those powers that you are given by the court, but allow the ward to make those decisions he/she is still able to make.

In order to know what decisions to make, a guardian or conservator should:

• Get to know the ward;
• Understand any needs or problems the ward may have;
• Be able to ask questions and seek opinions about different ways to meet the needs of the ward.

The Iowa statutes do not give much guidance on making decisions for someone else. Usually, courts consider what the ward would have done if the ward was able to make the decision. This is called substituted judgment. Sometimes courts consider what is in the ward's best interest. Often using either of these standards will result in the same decision. Decisions should be made with informed consent. These concepts are explained below.

What is Substituted Judgment?
Substituted judgment means the guardian or conservator makes decisions for the ward based on how the ward would have decided for himself or herself if the ward could decide. This works best if the guardian or conservator knew the person when he or she was able to make decisions. The guardian or conservator should also review any written statements made by the ward. The guardian or conservator should talk to the ward and others who have known the ward for a long time.

What is Best Interest?
If the ward has always been considered incapacitated, it can be harder to figure out what the ward would do if able. An example is a person with a developmental disability.  The conservator or guardian should talk to the ward. Even if the ward was able to make decisions in the past, it can be hard to know what the ward would do. When there is no good information about what the ward would do, it is proper to make a decision based on what is in the ward's best interest.

In applying a best interest standard, a guardian or conservator considers the benefits and harms to the ward of a particular act or course of action based on reasonable alternatives. The guardian or conservator then selects a reasonable alternative that provides the most benefit and least harm. The ward's wishes should also be considered. These decisions require the guardian to know enough about the ward in order to make decisions on the ward's behalf that are in his or her best interest.

What is Informed Consent?
In making decisions for a ward, the guardian or conservator may need to consent or agree to some treatment or course of conduct. Consent should usually be informed consent. The concept is most often used in the context of health care treatment but can be used in other areas as well. "Informed consent" means that consent is valid only if the person giving the consent understands:

• the nature of what is being consented to;
• the benefits and/or the risks of harm; and
• what the available alternatives are to the ward if consent is, or is not, given.

The person giving consent should be able to give a reason for selecting a particular alternative.

Informed consent requires that the person giving consent:

• has the knowledge available to make a reasonable decision;
• has the capacity or ability to make reasoned decisions based upon information that applies to the situation; and
• is giving consent voluntarily and without coercion. That is, there is no intimidation or pressure from another person.

Consent or Denial Checklist
Review the questions below when making a consent determination. If the answer is "no" to any of the questions, the guardian or conservator should stop and get the necessary information in order to continue with the decision making process.

• Has the court modified the ward's rights in this area?
• Does the guardian or conservator have the legal authority to make the decision?
• Does this consent require court review and approval?
• Does the guardian or conservator understand the nature of what is being consented to?
• Does the guardian or conservator understand the benefits and/or the risk of harm to the ward if consent is, or is not, given?
• Has the guardian or conservator weighed the benefits and/or the risk of harm?
• Does the guardian or conservator know about alternatives?
• Can the guardian or conservator give a reason for selecting this particular alternative?
• Has the guardian or conservator considered the ward's preferences or been able to determine what the ward would have decided if still competent?
• Has the guardian or conservator talked to any necessary experts to get their opinions?
• Are all interested parties in agreement with this decision?
• Is this decision a reasonable decision that would be made for any person regardless of disability, age, race, ethnicity, or place of residence?
• Has the guardian or conservator determined what funding resources are necessary and available to pay for this alternative?
• Is the necessary funding available?

Funding for this information was provided by the Iowa Governor's Developmental Disabilities Council.