U.S. states vary in their procedures for appointing and challenging default surrogates, the attributes they require of them, priority ranking of possible decision makers, and dispute resolution — with important implications for clinicians, patients, and public health.

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

Dr. Mueller reports receiving consulting and lecture fees from Boston Scientific. No other potential conflict of interest relevant to this article was reported.

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From the Division of Pulmonary and Critical Care Medicine (E.S.D.), the Biomedical Ethics Research Program (E.S.D., B.P.S., P.S.M.), and the Division of General Internal Medicine (P.S.M.), Mayo Clinic, Rochester, MN; the MacLean Center for Clinical Medical Ethics, University of Chicago (E.S.D., C.K.D., M.S.), the Beazley Institute for Health Law and Policy, Loyola University Chicago School of Law (S.E.G.), and the Department of Medicine, University of Chicago Medical Center (M.S.) — all in Chicago; the Departments of Medicine and Philosophy, Georgetown University, Washington, DC (D.P.S.); and the Division of Cardiology, Massachusetts General Hospital (D.M.D.), Harvard Medical School (D.M.D., D.B.K.), and the Richard A. and Susan F. Smith Center for Outcomes Research, Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center (D.B.K.) — all in Boston.