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This chapter explains the burdens of surrogate decision-making decision-making citing a case study of an 80 year-old widowed woman admitted for elective total hip replacement but post-surgery loses the decision-making capacity. Many European countries have autonomy-based models of decision-making for competent patients, and hierarchies for surrogate decision-making for incapacitated patients that are similar to that in the US. It may be possible to prevent confusion about the appropriate surrogate by asking all hospitalized and preoperative patients with decision-making capacity to identify their preferred surrogate decision maker(s) early in their hospital stay. Ethics and palliative care consultants can help evaluate apparent discrepancies. Decision-making capacity is assessed by evaluating patients' abilities to understand information about their condition and treatment options; appreciate that the decision at hand will affect them; explain their reasoning; and arrive at a choice consistent with their values and beliefs or a discussion of the patient's life and values.