In modern era medicine, patient's autonomy is held in the epitome of medical decision making. When patients lose decision making capacity, providers try to the best of their ability to uphold patient's pre-expressed wishes. Substituted judgment can take many forms, such as consulting with next of kin, surrogate decision makers, court appointed guardian, and emergency consent. The goal is to answer: What is in the patient's best interest and what would the patient want if they could speak for themselves?

We present a case of an elderly patient with a diagnosis of terminal lungcancer with metastasis to the brain, liver, and bones who presented with complaints of weakness and altered mental status. Although the patient could not speak, they exhibited signs and symptoms of severe pain. The surrogate refused to provide the patient with analgesics. The ethics committee was consulted to help navigate the situation and facilitate a solution. We discuss in this manuscript some important background and guiding ethical principles and describe how our case resolved.

Substituted judgment is considered a basic guiding principle when making decisions for incapacitated patients; where providers and surrogate decision makers try to make decisions that the patient would have made. Literature illustrates that this framework is not free of fault. Our case emphasizes the importance of understanding the guiding principles in medical ethics and consulting the ethics department when unclear.

Though the pursuit of substituted judgment is well-intended, it is not infallible. It is important to recognize this when having discussions with surrogate decision makers and understanding that alternative models could be a better fit in certain situations. All while trying to the best of the provider's ability to uphold patient's wishes and best interests.