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Physician and Surrogate Decision-Maker Interactions

By June 2, 2016Commentary

In the worry about controlling health spending, what happens to a relatively few patients near the end of life is of significant concern, as they account for a large percent of all spending.  Many, if not most, of these patients do not and cannot make decisions for themselves.  Being a surrogate decision-maker for a critically ill patient is unbelievably difficult.  Conflicts with physicians and other clinicians are not unusual and research in the Journal of the American Medical Association explores the dynamics of these relationships.   (JAMA Article)   These surrogate decision-makers have been shown in past research to often have more optimistic prognostic perceptions for the patient than the doctor does.  It is unclear why this is the case–are surrogates misunderstanding the physician, is the physician not straightforward enough, are there just optimism biases that influence decisions.  The authors in this study used critically-ill patients at four ICUs as a source for assessment of prognostic outlook and  factors in differences between surrogate and clinician views.  Both surrogate and physician were asked to provide a percent chance the patient survives the hospitalization.  The surrogates were also interviewed about why they held the perception they did.

In about half of 229 cases, there was a significant disagreement in the prognostic perception.  More than 80% of the time, the surrogate was more optimistic than the physician.  Most of the time the difference related to a misunderstandings by the surrogate of the relevant information, with a significant role played by different beliefs or values as well.  One thing to note is that physicians, as we would expect and hope, were much more accurate than the surrogates in their perceptions of likely outcome.  Surrogates rationalized their greater optimism by saying they knew the patient better, they believed in the power of positive thinking or because of their religious beliefs.  On those rare occasions when the surrogate was more pessimistic than the doctor, it was usually because the surrogate thought the doctor was being too optimistic.  The biggest danger from undue optimism is that this can lead to expensive end-of-life interventions that have little value and degrade a patient’s quality of death.  How to help surrogates avoid this is unclear.  This is an unavoidably emotional situation and helping surrogates understand the likely thought processes they are experiencing can only go so far.

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