Who Makes Medical Decisions if No Power of Attorney in Tennessee

When a Tennessee resident loses decision-making capacity — after a stroke, during surgery, or as dementia progresses — someone must authorize or refuse medical treatment on their behalf. If you haven't named a healthcare agent in an advance directive, Tennessee law assigns that authority through a default surrogate hierarchy. The result may not be who you'd choose.

The Default Surrogate Hierarchy

Under T.C.A. § 68-11-1806, when no advance directive exists and no healthcare agent has been designated, the supervising physician identifies a default surrogate from this descending order:

1. Spouse (unless legally separated)
2. Adult child
3. Parent
4. Adult sibling
5. Any other adult relative
6. An adult who has shown special care and concern for the patient and is familiar with their values

The physician must also document the patient's incapacity and the rationale for selecting the specific surrogate. This isn't a casual decision — the physician must determine that the patient lacks the ability to understand and appreciate the nature and consequences of a healthcare decision.

What a Default Surrogate Cannot Do

A default surrogate who was not personally chosen by the patient faces a hard legal limit that a named healthcare agent does not: they cannot authorize withholding or withdrawing artificial nutrition and hydration.

The only exception is narrow. Two physicians — the designated physician and an independent second physician — must certify in writing that:

• Continuing nutrition or hydration would merely prolong the active dying process
• The patient is highly unlikely to regain decision-making capacity

Without both certifications, a default surrogate's hands are tied on this specific decision, even if every family member agrees the patient would not want tube feeding.

A named healthcare agent has no such restriction. If you've designated an agent in your advance directive, they can authorize withdrawal of nutrition and hydration based on your documented wishes and their understanding of your values — no additional physician certifications required.

When Surrogates Disagree

The default hierarchy assumes one person fills the role. But what happens when three adult children share priority level 2 and disagree about their parent's treatment?

Tennessee law offers no tiebreaker. The healthcare facility cannot resolve conflicts between surrogates of equal priority. The only path forward is for a family member to petition the county court to appoint a Conservator of the Person — a court-supervised guardian with legal authority to make healthcare decisions.

Conservatorship proceedings require:

• Filing a petition with the county court
• Attorney representation for both the petitioner and the incapacitated person
• A hearing where the court evaluates capacity and appoints a conservator
• Ongoing court oversight of the conservator's decisions

This process takes weeks to months, costs thousands of dollars in legal fees, and happens during the most stressful period a family can face. Meanwhile, treatment decisions may be delayed or made by default (physicians continuing the current course of care) rather than by anyone who knows the patient's wishes.

Why the Hierarchy May Not Match Your Preferences

The statutory order reflects a generic assumption about family relationships. In practice:

• A spouse may be estranged but not legally separated — they still top the hierarchy
• An adult child living across the country may outrank a close friend who has been your primary caregiver for years
• Multiple adult children at the same priority level can deadlock decisions
• A parent with their own cognitive decline may technically hold priority over a sibling who knows you better

The hierarchy also doesn't account for family dynamics. An adult child who disagrees with your values about end-of-life care has the same priority as one who understands and respects them.

The Fix Is Straightforward

Naming a healthcare agent in a Tennessee Advance Directive for Health Care overrides the entire default hierarchy. Your chosen agent gains authority the moment your physician determines you lack capacity — no court involvement, no family voting, no physician certifications for nutrition and hydration decisions.

You can also name alternates, so if your primary agent is unavailable, your backup steps in rather than the default hierarchy. And you can include specific instructions in the Individual Instructions section that guide your agent's decisions, removing ambiguity about your preferences.

The Tennessee Advance Directive & Living Will Kit walks you through choosing and appointing your healthcare agent, setting up alternates, and documenting the specific treatment preferences that prevent family conflict during a crisis.

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