Background <p>Informed consent is a fundamental ethical requirement in medical practice and an expression of respect for patient autonomy. However, when adult patients lack decision-making capacity and no legal representative is available, Polish law requires substitute consent from a guardianship court. Empirical data on this mechanism in routine clinical practice remain limited.</p> Methods <p>We conducted a retrospective review of court petitions submitted by a tertiary academic medical center in eastern Poland seeking judicial authorization for medical procedures involving adult patients between June 2019 and June 2024. In total, 240 case files were analysed, including data on patient characteristics, causes of incapacity, requested procedures, court decisions, and time to judicial decision.</p> Results <p>The median patient age was 73 years (interquartile range 62–83), and 76.7% of patients were aged 61 years or older. The most common cause of incapacity was impaired verbal–logical communication (65.0%), followed by unconsciousness (20.8%) and dementia (7.5%). The most frequently requested procedures were blood transfusions or administration of blood products (<i>n</i> = 201), placement of a percutaneous endoscopic gastrostomy tube (<i>n</i> = 149), and tracheostomy (<i>n</i> = 27). Court authorization was granted in 97.1% of cases, with a median decision time of 5 days.</p> Conclusions <p>Judicial substitute consent in Poland primarily concerns older patients with acute neurological impairment or advanced multimorbidity. Although approval rates are high and median processing times are relatively short, even brief delays may have clinically and ethically significant consequences in time-sensitive situations. These findings highlight the need to balance legal safeguards, patient autonomy, and timely access to care.</p>