Magazine article Clinical Psychiatry News

Patient-Chosen Surrogates Have a Role, Says Study

Magazine article Clinical Psychiatry News

Patient-Chosen Surrogates Have a Role, Says Study

Article excerpt

When making treatment decisions for incapacitated patients, the wishes of family members are "generally respected as a key element of decision making," despite professional guidelines that recommend putting the patient's wishes first, results of an interview-based study show.

The U.S. courts and professional organizations such as the American Medical Association have advocated putting the patient's wishes first, but this autonomy-based approach is limited by the lack of advance directives or living wills for most patients. And even patient-chosen surrogates have been shown to be inadequate at predicting what patients would want, according to Dr. Alexia M. Torke of the Indiana University Center for Aging Research, the Regenstrief Institute Inc., and the Fairbanks Center for Medical Ethics, Indianapolis, and her colleagues (J. Clin. Ethics 2008;19:110-9).

"The findings suggest that physicians' decision-making framework was broader and more complex than previously thought," they said.

Using semistructured, in-depth interviews, the investigators sought to determine how physicians make care decisions about adult inpatients who lack decisionmaking capacity.

The researchers interviewed 21 physicians from a Midwestern academic medical center, of whom 13 were men and 15 were white. Six were interns, eight were residents, one was a fellow, and six were attendings. Of these, 20 had made a major medical decision for an incapacitated patient within the previous month.

Each interview consisted of open-ended questions and was audiotaped and transcribed. The transcripts were analyzed by two of the study researchers to identify the major themes, and these themes were explored further in subsequent interviews.

The three major themes regarding physician decision making for such patients were: patient-centered ethical guidelines, or the patient's wishes and best interest; surrogate-centered ethical guidelines, or the wishes and interests of the decision-making surrogates for the patient (usually family members); and issues of knowledge and authority for both the physician and surrogates.

In the absence of an advance directive or living will, physicians sometimes try to ascertain what the patient would want by asking family members about the patient's values and any relevant previous statements, Dr. Torke and her colleagues said. Physicians also took into account their own assessment of the patient's pain and suffering and quality of life when deciding the course of care, they said. …

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