The limits of proxy decision making: undertreatment

Exploring variables related to medical surrogate decision-making accuracy during the COVID-19 pandemic

OBJECTIVE

Surrogate medical decision making is common in the United States healthcare system. Variables that may influence surrogate decision making have been proposed. Little work has examined relations between these variables and outcomes of surrogate decision making. This study investigated whether surrogates' characteristics, including their knowledge of treatment options, and interpersonal factors predicted surrogates' accuracy and intervention selections. Specifically, predictor variables included: trust in the medical profession, trait-level anxiety, depression, anxiety about COVID-19, religiosity, perceived emotional support, understanding of treatment options, empathy, willingness to accept responsibility for medical decisions, reluctance to burden others, and perceived similarity between oneself and the patient.

METHODS

154 pairs of patients and their surrogates completed an online survey. Patients indicated preferred treatments in hypothetical decision scenarios. Surrogates indicated the treatment that they thought the patient would prefer.

RESULTS

When taken all together in a predictive model, the variables significantly predicted surrogates' accuracy, F (6) = 3.03, R² = .12, p = .008. Variables also predicted selection of intensive interventions, F (4) = 5.95, R² = .14, p = .00. Surrogates reporting greater anxiety about COVID-19 selected more intensive interventions.

CONCLUSIONS

Consistent with prior research, this study found that surrogates' characteristics influence the interventions they choose, with anxiety about COVID-19 having considerable bearing on their chosen interventions.

PRACTICE IMPLICATIONS

These findings can inform development of decision-making interventions to improve surrogates' accuracy. Providers may attend to variables highlighted by this study to support surrogates, particularly within the stressful context of COVID-19 and possible future pandemics.

Development and Validation of the Readiness for End-of-Life Conversations (REOLC) Scale

Background: Engaging in end-of-life care considerations is beneficial when the time is right. The purpose of this study is to provide a valid instrument to assess peoples readiness for end-of-life conversations before they are initiated. Materials and Methods: A community sample was recruited in study one for exploratory factor analysis of a 13-item questionnaire. In study two, psychometric properties were analyzed with structural equation modeling in a population affected by cancer. Convergent and discriminant validity were assessed with questionnaires measuring distress, depression, anxiety, fear of progression, and distress of death and dying. Results: In study one (N = 349) exploratory factor analysis resulted in three subscales readiness (α = 0.84), communication (α = 0.76), and values (α = 0.56) with a possible common factor (α = 0.84) for a community sample. In study two (N = 84) the three-factor solution with 13 items was not supported for cancer patients. Factor structure was adapted to 12 items with one common factor readiness (α = 0.87). Model fit was good: χ²(50) = 59.18, p>0.05 (Satorra-Bentler-correction = 1.27), with χ²/df = 1.184, rRMSEA = 0.053 (90%-CI[0.000;0.100]), and rSRMR = 0.072. Convergent validity was supported by moderate correlations to trait gratitude, ratings of readiness to provide a living will or talk with family about the end of life. Divergent validity was supported by no or small correlation with distress, depression, general and death anxiety and fear of progression, respectively. Conclusions: Results support usage of the REOLC Scale in different settings with adapted factor structure. The questionnaire is interpreted as valid and reliable instrument to assess objective readiness for end-of-life conversations.

Decision making in health care: limitations of the substituted judgement principle

The substituted judgement principle is often recommended as a means of promoting the self-determination of an incompetent individual when proxy decision makers are faced with having to make decisions about health care. This article represents a critical ethical analysis of this decision-making principle and describes practical impediments that serve to undermine its fundamental purpose. These impediments predominantly stem from the informality associated with the application of the substituted judgement principle. It is recommended that the principles upon which decisions are made about health care for another person should be transparent to all those involved in the process. Furthermore, the substituted judgement principle requires greater rigour in its practical application than currently tends to be the case. It may be that this principle should be subsumed as a component of advance directives in order that it fulfils its aim of serving to respect the self-determination of incompetent individuals.

The limits of proxy decision making: overtreatment

Traditionally, surrogates have been involved principally in making decisions about life-sustaining treatment for incompetent individuals. Today, surrogates are increasingly called upon to make everyday medical decisions for patients who are incompetent because they are demented. Some of the potential perils of proxy decision making under these circumstances have been identified, including the lack of concordance between patients and their proxies, demands by proxies for technically futile therapy, and actual abuse of patients. We found a significant number of cases in which healthcare providers at a long-term care facility came into conflict with surrogates because the treatment desired by the surrogate was viewed as excessively burdensome when evaluated by an experienced team of nurses, physicians, and social workers. Neither a court-appointed guardian nor an Institutional ethics committee were likely to be able to resolve these conflicts because of lack of clarity about what constitutes the best Interest of Impaired nursing home patients. The following case illustrates this increasingly common conflict.