Myth of substituted judgment. Surrogate decision making regarding life support is unreliable

Suhl, Jeremiah; Simons, Pamela; Reedy, Terry J.; Garrick, Thomas

doi:10.1001/archinte.154.1.90

Cited by 136 publications

(116 citation statements)

References 10 publications

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“…These findings may reflect lessening reluctance to discuss death and dying in contemporary Western societies (Clark, 1993;Davis & Higginson, 2004;Seale, 2000;Timmermans, 1999). Suhl et al (1994) reported that the more discussions the older adult and their family members had regarding older people's feelings about receiving life support, the more accurately the surrogate understood the wishes of their relative regarding life sustaining treatment. Thus, if family members are to be involved in resuscitation decisions, they need to discuss these issues with their relative.…”

Section: Discussionmentioning

confidence: 99%

Family members' perspectives on potential discussions about life prolongation for their older relatives

et al. 2008

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Family members (or health-care confidants) of incapacitated patients are often consulted by doctors when making life-prolongation decisions. Little research has been conducted on confidants' views on life prolongation and advance care planning. This study investigated the health-care confidant's view on life prolongation and their involvement in being a potential decision-maker for their relatives in the event of incapacitation. Confidants (N ¼ 12) were interviewed and interviews were analysed using Interpretative Phenomenological Analysis. The analysis revealed three themes relating to their perception of being a potential decision-maker for a relative's life prolonging measures: ''good'' and ''bad'' death based on past experience and perceptions of quality of life, a sense that discussions were inappropriate at present, and strategies which might be used to encourage discussion. The implications of these findings for family involvement in life-prolongation decisions and how to encourage family discussions about life prolongation are discussed.

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Section: Discussionmentioning

confidence: 99%

Family members' perspectives on potential discussions about life prolongation for their older relatives

et al. 2008

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Section: Model-the Structural Equations Describing the Model Arementioning

confidence: 99%

“…5 Where items are structured to permit such responses, expressed preferences do vary continuously (Libbus and Russell 1995;PrincipeRodriguez et al 1999;Seckler et al 1991;Suhl et al 1994;Sulmasy et al 1998). where η 1 = surrogate preferences (latent); η 2 = spouse preferences (latent); Y PG = surrogate response for self, pain condition; Y CIG = surrogate response for self, cognitive impairment condition; Y P'S = surrogate report on spouse preference, pain condition; Y CI'S = surrogate report on spouse preference, cognitive impairment condition; Y PS = spouse response for self, pain condition; Y CIS = spouse response for self, cognitive impairment condition; the λ ij are coefficients to be estimated, and the ε i are random errors. In addition to the λ ij , the parameters of the model are the variances and covariances of the latent preferences (Ψ j ) and the variances and covariances of the errors in variables .…”

Section: Model-the Structural Equations Describing the Model Arementioning

confidence: 99%

Do Older Adults Know Their Spouses' End-of-Life Treatment Preferences?

Moorman¹,

Hauser²,

Carr³

2009

ICPSR Data Holdings

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When terminally ill patients become mentally incapacitated, the patient's surrogate often makes treatment decisions in collaboration with health care providers. We examine how surrogates' errors in reporting their spouse's preferences are affected by their gender, status as durable power of attorney for health care (DPAHC), whether the surrogate and spouse held discussions about end-of-life preferences, and the spouse's health status. We apply structural equation models to data from 2,750 married couples in their mid 60s who participated in the 2004 wave of the Wisconsin Longitudinal Study. Surrogates reported their spouse's preferences incorrectly 13 and 26 percent of the time in end-of-life scenarios involving cognitive impairment and physical pain, respectively. Surrogates projected their own preferences onto the spouse. Similar patterns emerged regardless of surrogate gender, surrogate status as DPAHC, marital discussions about end-of-life, or spousal health status. We discuss implications for the process of surrogate decision-making and for future research.As recently as 1960, nearly all physicians were opposed to telling their patients that they had terminal cancer, because they believed that the knowledge would have shattering psychological effects (Oken 1961). Subsequent psychosocial research showed that the awareness that one is dying does not emotionally harm a patient (Kübler-Ross 1969). Physician attitudes evolved such that the standard for care is now full disclosure and collaboration among patients, health care providers, and surrogate decision-makers in cases where the patient is unable to convey his or her own treatment preferences (Brody 1997;Novack et al. 1979;Snyder and Leffler 2005). Changes in physician attitudes have occurred alongside policy changes: In 1990, Congress passed the Patient Self-Determination Act (PSDA) to ensure that dying people have a greater say in their care. Under this law, federally funded health care providers are required to give patients information that helps them to execute a living will and to legally appoint a surrogate, known as a durable power of attorney for health care (DPAHC), to oversee their care in the event of decisional incapacitation.A concern of patients and health care providers is that surrogates accurately convey the patient's wishes. An effective surrogate, according to bioethicists, is someone who can apply the standard of substituted judgment (President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research 1983). Substituted judgment occurs when the surrogate makes the medical decision that the patient would have made if he or she (Shalowitz, Garrett-Mayer, and Wendler 2006). Surrogates often presume (erroneously) that the patient's preferences are identical to their own: Surrogates' own preferences account for more of the variance in their decisions than do the patients' actual preferences (Bar-Tal, Barnoy, and Zisser 2005;Fagerlin et al. 2001;Pruchno et al. 2005). Study AimsOur primary goal ...

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“…[18][19][20][21][22][23][24] In particular, surrogates who are chosen by patients specifi cally because they are personally close may have a hard time of letting go of their relationship; choosing against life-sustaining treatment may result in a patient's death, thereby severing the relationship. 23,24 Given that patients elect to trust the judgment of legal surrogates, however, such decisions would not violate the patients' autonomy.…”

Section: Pathways To Life-sustaining Treatment By Defaultmentioning

confidence: 99%

Preventing Life-Sustaining Treatment by Default

Braun¹,

McCullough²

2011

The Annals of Family Medicine

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Many physicians will at some point care for patients who will receive life-sustaining treatment by default, because there are no instructions available from the patient as to what kind of care is preferred, and because surrogates are likely to ask for everything to be done when they do not know a patient's preferences. We use the methods of ethics informed by qualitative focus group research to identify 5 pathways to life-sustaining treatment by default originating with the patient's preferred decision-making style: deciding for oneself or letting others decide. We emphasize preventing the ethically unwelcome outcome of lifesustaining treatment by default by increasing the frequency with which patients make clear decisions or clearly express their values and goals that they then communicate to physicians or surrogates. 2011;9:250-256. doi:10.1370/afm.1227. Ann Fam Med INTRODUCTIONL ife-sustaining treatment by default refers to receiving resuscitation, intubation, and mechanical ventilation; vasopressor and intensive care unit support; and administration of other life-sustaining treatments, such as artifi cial feeding or transfusions, in the absence of guidance from a seriously ill patient who either did not make decisions or did not, orally or in writing, clearly communicate his or her end-of-life decisions effectively to others. We describe different decision-making pathways taken by the patient that result in the administration of life-sustaining treatment by default.Life-sustaining treatment by default is fraught with potential ethical confl ict that can take a considerable and unwelcome biopsychosocial toll on patients, their surrogates, and clinicians. [1][2][3][4][5] As a consequence, life-sustaining treatment by default can distort an organization's culture by promoting attitudes of indifference toward patients receiving lifesustaining interventions for whom such interventions make little clinical sense, or by contributing to increased burnout in nursing staff caring for such patients. End-of-life decision making for patients who have not made or communicated their decisions can place an inordinate psychosocial and moral burden on surrogates, who may be struggling with a role they did not want or were unprepared to assume. 3,6 When surrogates are unable to report a patient's preferences, they can feel overwhelmed, which likely increases requests for everything to be done even when such interventions are thought to be futile. 7 The ethical challenges of such requests are compounded when physicians label surrogates as diffi cult or irrational, leading to a breach of trust and problems in communication between clinicians and surrogates. 4 The purpose of this article is to propose an ethically justifi ed strategy 8,9 to prevent life-sustaining treatment by default. We begin by identifying the concept of life-sustaining treatment as a trial of intervention and describe 3 factors that can combine to create life-sustaining treatment by LIFE-SUSTAINING TREATMENT AS A TRIAL OF INTERVENTIONLife-sustaining ...

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Myth of substituted judgment. Surrogate decision making regarding life support is unreliable

Abstract: Substituted judgment by surrogates is not more accurate than random chance. Discussion between patient and surrogate about life support correlated with more accurate substituted judgment.

Cited by 136 publications

References 10 publications

Family members' perspectives on potential discussions about life prolongation for their older relatives

Family members' perspectives on potential discussions about life prolongation for their older relatives

Do Older Adults Know Their Spouses' End-of-Life Treatment Preferences?

Preventing Life-Sustaining Treatment by Default

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