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How do doctors really feel about surrogate decision making?

September 09, 2009

INDIANAPOLIS - A growing number of hospitalized adults are incapable of making their own health decisions, but little research has explored how doctors feel about making medical decisions with a patient's surrogate decision maker.

A study published in the September 2009 issue of the Journal of General Internal Medicine found that one in five doctors are not comfortable working with a surrogate decision maker. The doctors surveyed reported ineffective communication, lack of satisfaction with the outcome of the decision, and an increase in stress level as a result of the surrogate decision making process.

"We have come to consensus in our society that people should have a lot of input into their own medical decisions. But when the patient can't made decisions we have much less consensus on how to proceed. For example, we aren't as certain if the family should have as much discretion as patients would if they could make their own decisions or if the physicians should assume some of the responsibility," said Alexia Torke, M.D., senior author of the study. Dr. Torke is assistant professor of medicine at the Indiana University School of Medicine and a Regenstrief Institute investigator.

A surrogate decision maker often becomes involved in the care process only after the patient is critically ill and concerns are being raised about the futility of continued medical care and the value of life. These are very difficult issues for both physician and surrogates and often ones which neither party discussed with the patient when that individual was still competent to make decisions about care preferences.

The study surveyed 281 doctors, primarily internists, family practice doctors, intensive care unit physicians and hospitalists, about half of whom were in private practice. Slightly over half were male. Three-quarters of the physicians reported having made a major decision with a surrogate during the past month. Most of these surrogate decisions involved some aspect of life sustaining care for older adults. A quarter of the doctors stated that surrogate decision making caused them a great deal of distress.

"A significant percentage of decisions faced by surrogates involve changing aggressive care to comfort care, when medical options have been exhausted. Making a decision to change the focus of therapy is often a very difficult one for the surrogate, who may be a close family member and under a great deal of stress due to the patient's illness. Often, neither the physician nor the family knows what course of treatment the patient would have elected. Physicians reported that they also feel significant distress when make these decisions," said Dr. Torke, who is also with the Fairbanks Center for Medical Ethics at Clarian Health.

She notes that although only a small percent of patients lacked an identified surrogate, physicians often had trouble reaching the surrogate to make critical decisions. Additionally, few patients had ever expressed prior written or oral preferences for care.

Asian physicians, who comprised 28 percent of the doctors surveyed, were less likely to report agreement with surrogates than white or African American physicians. The study did not differentiate between American born and foreign born Asian physicians who may have experience language difficulties in communicating with surrogate decision makers. Dr. Torke says further research is needed to explore why Asian doctors reached lower levels of agreement with surrogate decision makers.

Indiana University