To the Editor Dr Cohen and colleagues1 drew attention to potential quality gaps in surrogate decision making for patients, including patients in the Veterans Health Administration (VHA). We would like to point out that both federal regulation governing the VHA2 and VHA policy3 establish a surrogate hierarchy that includes persons outside the nuclear family and authorizes them to make health care decisions on behalf of patients without decisional capacity. Specifically, that hierarchy is: health care agent, legal guardian, next of kin (ie, a relative ≥18 years of age in the following order: spouse, child, parent, sibling, grandparent, grandchild), and finally a close friend.
Alfandre D, Sharpe VA, Berkowitz K. Surrogate Decision Making for Patients Without Nuclear Family. JAMA. 2015;314(4):407-408. doi:10.1001/jama.2015.7245