Despite two decades of concerted effort from the healthcare industry, a majority of hospitalized patients with a serious illness have no documented advance directives. Advance directives voice patients’ decisions on important healthcare decisions and designate and empower surrogate decision-makers as Power of Attorney for Healthcare (POAHC). POAHC’s decide or carry out healthcare choices when the patient is incapacitated. Studies show, however, POAHC’s often fail to make the decision that is indicated by the patient’s preference. Some healthcare professionals question the adequacy of a single POAHC, though it is common practice to designate only one primary surrogate. The aim here is not to address industry standards with regard to POAHC designees, but to offer a framework to navigate issues that healthcare staff may utilize to address the decision-making capacity of the POAHC designees. Given the growing number of persons living into very old age and the increasing numbers of persons suffering from Alzheimer’s and other cognitive deficits, designated POAHC’s are more likely to have conditions that impede decision- making capacities. Furthermore, healthcare teams may struggle with impairment of a POAHC decision-maker due to psychological issues, substance abuse, mental illness, conflict of interest, or replacement of the surrogate’s own personal values and judgements for those of the patient. A number of ethical and legal issues are involved in cases where POAHC’s capacities are faulty or questionable. Central issues are whether the surrogate’s decision represents the patient’s own best interests and whether the decision is a fully-informed reasonable choice. When issues of incapacitated surrogates arise, the healthcare system has limited options for removing the incapacitated decision maker. Failure to effectively manage such situations can result in poor outcomes for patient care and excessive burdens for the healthcare system. Instead, care teams must look for ways to evaluate those whose decision-making we question and look for alternatives to the decision-making process while still providing optimum patient care. Many cases where surrogate decision-making is questionable lead to inappropriate or overly lengthy hospital stays. I propose a two-pronged method to evaluate POAHC decision making with a focus on the substance of the surrogates’ decisions and on the hospital responses. I will offer a framework to identify and clarify troublesome issues to facilitate healthcare providers’ navigation of potentially complex ethical and legal situations. Specifically we aim to identify a threshold for when it is appropriate to pursue legal channels to remove POAHC’s verses a reasoned response for allowing surrogate decisions which may seem questionable.