Patients' Surrogates Often Wrong About Preferred Treatment
Tuesday, March 14, 2006
Suppose you had a stroke and were in a coma for months, breathing with the help of a respirator. Now your doctor wants to know: If your heart stops, do you want to be revived?
You cannot answer, but someone you chose as your surrogate decision maker for just this situation can. The question is, will that person's decision accurately reflect your wishes?
Modern medicine assumes the odds are good, especially when the surrogate is a family member or friend you selected in advance. But a new analysis of 16 role-playing studies, in which volunteer patients and their designated surrogates confronted hypothetical health care decisions, indicates that surrogates get it wrong fully one-third of the time.
Surrogates chosen in advance were just as likely to misjudge a patient's preference as family members who were asked to step in with no warning. Even those who fully discussed the issue with the patient beforehand were no more likely to get it right.
Relying on doctors to decide is not the solution, said research leader David Wendler of the National Institutes of Health. They are even worse at predicting a patient's wishes. All told, he said, the findings suggest that today's system of decision making for incapacitated patients is in need of serious medical attention.
"We need to see if we can come up with a plausible alternative," said Wendler, a philosopher who is chief of the unit on vulnerable populations at NIH's Department of Clinical Bioethics.
Under current laws, patients have the right to designate a surrogate to make decisions for them if they cannot. When none is designated, states generally delegate the responsibility to the next of kin.
Surrogates are supposed to consider not what they think would be best for the patient but what they believe the patient would want. That, however, works only if surrogates get it right.
The new analysis, published yesterday in the Archives of Internal Medicine, compiled information from previous studies in which 151 hypothetical scenarios were presented to 2,595 pairs of patient and surrogate. The patients were either actual patients whose lives were not really hanging in the balance or healthy subjects asked to imagine that they were incapacitated.
Surrogates were given descriptions of various medical predicaments and asked whether they thought the patient would want a particular medical intervention -- usually one that, in the doctor's judgment, was necessary to keep the patient alive. Separately, the patients themselves were asked what they would want.
Surrogates correctly predicted the patients' choices just 68 percent of the time -- a modest improvement over the 50-50 odds from chance alone. Some underestimated and others overestimated patients' wishes to be treated.
In the four studies that also asked doctors what they thought the patient would want, the physicians were right just 63 percent of the time.