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.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.