Surrogate Decision-makers and End-of-Life Care

Health care spending is a problem in the United States and much of the focus is on the relatively small number of patients who generate much of the spending.  One class of these patients is people near the end of their lives, who often receive intensive care that does little to improve their health or even lengthen their lives.  Many of these people are incapacitated and decisions about their care are often made by surrogates–spouses, children, friends–who usually are not guided by advance directives.  New research in the Annals of Internal Medicine looks at how these surrogates process prognostic information given to them by physicians and other caregivers.  (Annals Article)   The research studied 80 surrogates and looked at their interpretation of prognostic statements.  The research confirmed that surrogates often interpret prognostic information more optimistically than physicians understand it and intend it to be understood.  Participants tended to interpret statements about high likelihood of survival accurately, but tended to have an overly optimistic interpretation of statements conveying a high likelihood of death.  Further analysis and interviews suggest that this is due to surrogates own biases toward wanting to believe that survival will occur.  The implications for health care use are that these surrogates will then encourage greater use of treatments that have little to no chance of making any real difference.

One of the fastest growing areas of human knowledge is understanding of our own mental processes and behavior.  This has enormous applicability to health care, both in influencing people’s behavior regarding their health and their decisions about health care services and products.  Understanding the decision-making process is critical, but becomes more complex when surrogates are involved, as they often are in end-of-life care.  The disgraceful “death panel” label on needed and important discussions with patients about their end-of-life care has impeded progress.  All patients should be strongly encouraged and incented to provide detailed advance directives about their care in a terminal situation.  Not the smallest benefit of this would be saving a lot of emotional anguish for people who otherwise become surrogate decision-makers.  And when there are surrogates, they should be educated on the role their own cognitive biases may play in their decision-making.