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Surrogate Decision Making in the ICU


Imagine your loved one is very sick in the ICU. So sick that the ICU doctor believes that there is only a very small chance of survival, and even if your loved one survived, he/she would have significant, permanent disability. If you were placed in this position, how would you want to make decisions about continued intensive medical treatments to support his/her life? Would you want to make it on your own? Would you want to share the responsibility for this decision with the ICU doctor? Would you just want the ICU doctor to make the decision for you with our without your opinion?

Now imagine we ask the same questions to surrogate decision makers of critically ill, incapacitated adults. How do you think they would answer? We now have some idea of how thanks to a study authored by Sara Johnson and her colleagues at UCSF and University of Pittsburgh.

The study, currently in press but accessible early online, presented two clinical vignettes to 230 surrogate decision-makers for incapacitated, mechanically ventilated patients at high risk of death. One vignette was based on a decision regarding life support similar to the one described above, and the other was about selection of specific antibiotic agents to treat an infection.

The main results would make the traditional paternalistic doctor cry.  The vast majority of surrogates wanted either the final say (55%) or shared responsibility (40%) over value-sensitive life support decisions. Only 5% wanted the physician to have final control over these decisions (sorry Dr. House). Of note though, if you tally up where people fall in their preferences, 90% of surrogates wanted the opinion of a physician in these decisions. Further multivariate analysis revealed that low levels of trust in their loved one’s physician, male gender, and being a member of a non-catholic religion, were all significantly associated with surrogates’ preference for a higher degree of decisional control for the value-sensitive life support decisions.

The other interesting aspect of this study was that surrogates preferred significantly more control over the value-sensitive life support decision than decisions regarding technical aspects of care like antibiotic choice. Although, there remained a significant minority who wanted some authority in these decisions too.

So what do we do with these results? First, there is wide variability in how surrogates want to make decisions, so clinicians need to ask about decision-making preferences instead of just picking a one-size-fits-all model. Secondly, clinicians need to tell surrogates what their opinions and recommendations are, instead of just giving a deluge of information. Lastly, clinicians need to build trust in order for these recommendations to carry any sway in the decision making process.


by: Eric Widera

Comments

Jim Richardson said…
Eric, your commentary reminds me of the Special Article, "Arrogance," written by the venerable NEJM editor, Franz J. Ingelfinger, and published posthumously in the Journal on December 25, 1980: "A physician who merely spreads an array of vendibles in front of the patient and then says, 'Go ahead and choose, it's your life,' is guilty of shirking his duty, if not of malpractice." I'm no fan of paternalism, but if we physicians want to be seen as professionals and not as mere order takers, entering patients' wishes into some EMR, we need to reassert ourselves and offer our opinions to decision-makers when they will be helpful.
CyndiC, RN said…
When I see families being asked, "What do YOU want to do"?--I always think of that commercial on TV where the Doctor is telling the patient how to do his own open heart surgery over the phone and the confused patient responds--"shouldn't you be doing this"?

Why do MD's go to years of med school and training and not be able to give an opinion? Why do nurses go through school, continuing education, & have years of bedside experience and not be allowed to give an opinion?

I agree, I feel it is malpractice to ask a bewildered, frightened family member with little or know medical knowledge & less experience with these kinds of situations to be given a minimal amount of confusing information and then be asked to make the most important decisions of their lives!

In our fear of paternalism & lawsuits, we seem to be afraid anymore to even offer an educated opinion or advise. Doesn't that seem a bit unfair?
Dan Matlock said…
This is a key innovation of palliative care - to begin with an exploration of values.

Offering opinions with no understanding of values is paternalism.

Offering opinions with an understanding of the patient and their values is good patient-centered care.
clay m. anderson, md said…
as palliative care and critical care physicians/teams, our opinions and recommendations in light of the patient's and family's values matter a great deal, but just as important is our best gauge of the prognosis, both survival and recovery calculus, and burdens and benefits of disease directed vs. comfort-based treatment. Too often we all try to have a good discussion and put in the time and effort but the family has not heard from the neurologist or neurosurgeon or us that from a medical point of view the patient is not recoverable, or is very unlikely to communicate, sit, or leave an institution ever again. So the quadrad is: 1. prognosis, 2. options/burdens/benefits, 3. values and goals, and 4. opinion and recommendation
thanks all, and happy new year!
clay anderson, md
north kansas city

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