When studies have been done of how well surrogate decision
makers do in reflecting the wishes of the patient,
it's been found that overall surrogate
accuracy is about 70%.
What that means is, when you ask the patient,
well, if you were in this hypothetical situation,
what would you want done?
And then, you ask their surrogate decision maker,
if you envisioned what the patient would want,
you know, what do you
think they would say?
70% of the time, surrogate decision makers
get it right as to what the patient would want.
It's generally the case that accuracy
is going to be better
when it's a more serious condition
like permanent coma.
The surrogate can sort of envision how
the patient would think about that situation
and has better accuracy in predicting what
the patient would want in that circumstance.
Now, how surrogates err when they don't
get it right, that 30% of the time, it's a mixed-result.
So, whether they might provide, you know, unwanted
treatments that the patient would not have wanted
or they withhold treatments that the patient
would've wanted, it goes both ways.
So, accuracy, and we know that 70% of the time
that it's accurate but this, when they are inaccurate,
it can go either way of giving treatment
that the patient doesn't want
or not offering treatment when the
patient would've wanted it.
It's also the case that, you know, when they
look at it, surrogates generally tend
to choose what they would
choose for themselves.
It's hard for one person to put themselves
in the shoes of another.
So, even though they're trying to speak
on behalf of the patient,
often when they make these decisions,
they're thinking about,
"Well, if I were in this situation,
what would I want?"
That's part of just, you know, what we've
seen with surrogate decision makers.
There is an ultimate question of, well,
does the accuracy actually matter?
You know, is it really important that we make
sure that patient wishes are followed exactly?
There've been studies on that that'll talk
to you about in a second.
But when you think about it, who should
be making these decisions for a patient?
Is it the clinician? Is it a stranger?
Is it, you know, someone that's unfamiliar
with the patient or who's in the best position,
you know, the surrogate decision maker, you know,
if it's not the healthcare agent or healthcare proxy,
then, maybe it's a family member that at least knows a little bit
about the patient and their wishes and their values.
So, when it's been the case that,
you know, we find surrogates
are not accurately representing the patient's wishes, the patient
might still say, you know, "I want my wishes followed."
You know, regardless of what
the surrogate says, you know,
"If I put in an advanced directive these
particular wishes, I want them followed."
Why would they say that? So, particular
patients might say, "I want my autonomy upheld.
Make sure you follow my wishes."
It may be that some patients say,
"Well, I wanna protect my surrogate
from burdensome decision-making."
You know, it's hard to be a decision maker, so, I wanna relieve
them of that burden by saying, "Just follow my wishes."
That makes it a little easier for them when
they have to make decisions on my behalf.
It may also be the case that their concern that the surrogate
is going to be too emotional to make a decision.
They're going to vacillate in their decision
but if it's clear directions from the patient,
"These are my wishes. Follow them."
Better, you know, for the surrogate
to follow through on those.
Now, there may be times
where patients say,
"You know, regardless of what my wishes might be,
I want you to follow my surrogate's wishes
even if they're different from my own."
One, you know, they might say,
"Well, I trusted my surrogate's ability."
You know, they're faced with the situation.
They've heard all the information from the clinical team.
I trust their ability to make this decision.
Or they might say, "Well, I trust in my
relationship with the surrogate.
You know, I rely on them. You know, I've told them,
you know, just make the best decision best you can.
And I'll trust, you know,
whatever decision they make."
It may also be that they're concerned
about the surrogate's best interests.
You know, maybe in the situation, it's going to
be better for the patient to rely on
the surrogate's judgement rather
than the patient's own wishes.
So, again, it's mixed as to how
to think about this issue
but in general, when we're thinking
about surrogate decision-making,
you're going to rely on that priority list,
go down the list, try to find the person
that's best representative of the
patient's wishes and values.
Now, there may be times
when there are conflicts.
So, the surrogate conflicts with
what the patient would've decided.
Even when that happens, half of the time,
when studies that have been done,
patients would still opt to go with
their surrogate decision maker
and it's also important when you're
thinking about surrogate decision maker
of what's the balance of following the patient's
wishes versus following the surrogate's wishes.
When studies have been done, it's shown
that actually, patients want mutual decision making.
This is combining both the patient's
previously stated preferences
with what the surrogate thinks is in
the patient's best interest.
So, sort of a shared or mutual
That's how the surrogate
should make decisions.