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Background Increasing age is accompanied by a greater need for medical decisions, due in part to age‐related increases in chronic disease and disability. In later life, medical decisions about end‐of‐life care in particular are likely. However, a significant percentage of these decisions are made by surrogate decision‐makers. “Surrogates” are most often instructed to use the substituted judgment standard and make decisions that patients would choose if they were able. Whether surrogates make decisions that adequately match patients’ preferences is a concern. Surrogates are generally poor predictors of patient preferences (Shalowitz et al., 2006). However, no critical review of this literature has yet been published. Method A critical review was conducted to summarise and provide a methodological critique of 25 studies. Results These studies generally concur that patient–surrogate agreement on medical decisions is poor. However, this conclusion is qualified by inconsistencies in methodological quality and the potentially limited generalisability of these findings. Conclusions Clinical research incorporating standardised hypothetical decision‐making protocols, as well as triangulated data collection methods, would bolster confidence in future findings. Investigations prioritising the surrogate decision‐making process, rather than solely the decisional outcome, could better identify ways to improve the decision‐making process for incapacitated patients.

Objective Surrogate medical decision making is common in the United States healthcare system. Variables that may influence surrogate decision making have been proposed. Little work has examined relations between these variables and outcomes of surrogate decision making. This study investigated whether surrogates’ characteristics, including their knowledge of treatment options, and interpersonal factors predicted surrogates’ accuracy and intervention selections. Specifically, predictor variables included: trust in the medical profession, trait-level anxiety, depression, anxiety about COVID-19, religiosity, perceived emotional support, understanding of treatment options, empathy, willingness to accept responsibility for medical decisions, reluctance to burden others, and perceived similarity between oneself and the patient. Methods 154 pairs of patients and their surrogates completed an online survey. Patients indicated preferred treatments in hypothetical decision scenarios. Surrogates indicated the treatment that they thought the patient would prefer. Results When taken all together in a predictive model, the variables significantly predicted surrogatesʼ accuracy, F (6) = 3.03, R 2 = .12, p = .008. Variables also predicted selection of intensive interventions, F (4) = 5.95, R 2 = .14, p = .00. Surrogates reporting greater anxiety about COVID-19 selected more intensive interventions. Conclusions Consistent with prior research, this study found that surrogates’ characteristics influence the interventions they choose, with anxiety about COVID-19 having considerable bearing on their chosen interventions. Practice implications These findings can inform development of decision-making interventions to improve surrogates’ accuracy. Providers may attend to variables highlighted by this study to support surrogates, particularly within the stressful context of COVID-19 and possible future pandemics.

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The intergenerational stake hypothesis posits that older people tend to feel more positively about their relationships with younger people in their family because they have a greater perceived "stake" in the relationship. Pairs of grandparents and grandchildren ( n = 79) completed a brief survey that asked questions about relational closeness, shared activities, and relationship quality. Both self- and proxy reports were gathered from each participant. On average, grandparents reported significantly more favorable self-reports of emotional closeness than their grandchildren. However, proxy reports revealed that grandparents were actually quite accurate at predicting their grandchildren's relational closeness responses. Moreover, difference score calculations identified a portion of the dyad sample (39 dyads) that appeared to refute the hypothesis in their relational closeness responses. Results from this study suggest that the generational stake phenomenon exists in the grandchild/grandparent relationship. However, the degree to which grandparents are aware of their grandchildren's perspectives may vary.

Palliative care consultation teams (PCCTs) provide input to other health-care providers working with patients who have life-limiting disease. This study examines whether the diction and phrasing of consultation recommendations in the electronic health record influence their implementation. We reviewed 288 verbatim PCCT recommendations that were made for 111 unique patients in a Veterans Affairs hospital and available in the electronic health record. Recommendations were coded for linguistic features, such as the presence of conditionals (e.g., "could") and tentative phrasing (e.g., "would suggest"). Each patient's subsequent treatment was followed in the medical record to determine whether PCCT recommendations were implemented. Only 57% of the consultation recommendations were eventually implemented. Recommendations that included a conditional word or phrase were significantly less likely to be implemented. In particular, recommendations that included the words "could" and "consider" were less likely to be implemented. PCCTs may enhance their effectiveness by attending to the subtle pragmatics of how they communicate with other health-care providers, particularly in electronic communication where nonverbal features of communication are unavailable.

Background Population aging has increased the prevalence of surrogate decision making in healthcare settings. However, little is known about factors contributing to the decision to become a surrogate and the surrogate medical decision-making process in general. We investigated how intrapersonal and social-contextual factors predicted two components of the surrogate decision-making process: individuals’ willingness to serve as a surrogate and their tendency to select various end-of-life treatments, including mechanical ventilation and palliative care options. Method An online sample (N = 172) of adults made hypothetical surrogate decisions about end-of-life treatments on behalf of an imagined person of their choice, such as a parent or spouse. Using self-report measures, we investigated key correlates of willingness to serve as surrogate (e.g., decision-making confidence, willingness to collaborate with healthcare providers) and choice of end-of-life treatments. Results Viewing service as a surrogate as a more typical practice in healthcare was associated with greater willingness to serve. Greater decision-making confidence, greater willingness to collaborate with patients’ physicians, and viewing intensive, life-sustaining end-of-life treatments (e.g., mechanical ventilation) as more widely accepted were associated with choosing more intensive end-of-life treatments. Significance of results The current study's consideration of both intrapersonal and social-contextual factors advances knowledge of two key aspects of surrogate decision making — the initial decision to serve as surrogate, and the surrogate's selection of various end-of-life treatment interventions. Providers can use information about the role of these factors to engage with surrogates in a manner that better facilitates their decision making. For instance, providers can be sensitive to potential cultural differences in surrogate decision-making tendencies or employing decision aids that bolster surrogates’ confidence in their decisions.