Accuracy of Surrogate Decision Making

by Mark Hughes, MD, MA

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    00:01 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%.

    00:12 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.

    00:32 It's generally the case that accuracy is going to be better when it's a more serious condition like permanent coma.

    00:39 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.

    00:50 Now, how surrogates err when they don't get it right, that 30% of the time, it's a mixed-result.

    00:57 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.

    01:07 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.

    01:23 It's also the case that, you know, when they look at it, surrogates generally tend to choose what they would choose for themselves.

    01:30 It's hard for one person to put themselves in the shoes of another.

    01:33 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.

    01:47 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.

    02:01 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.

    02:26 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.

    02:50 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.

    03:10 It may also be the case that their concern that the surrogate is going to be too emotional to make a decision.

    03:15 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.

    03:28 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.

    03:47 I trust their ability to make this decision.

    03:50 Or they might say, "Well, I trust in my relationship with the surrogate.

    03:53 You know, I rely on them. You know, I've told them, you know, just make the best decision best you can.

    04:00 And I'll trust, you know, whatever decision they make." It may also be that they're concerned about the surrogate's best interests.

    04:08 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.

    04:18 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.

    04:36 Now, there may be times when there are conflicts.

    04:40 So, the surrogate conflicts with what the patient would've decided.

    04:43 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.

    05:02 When studies have been done, it's shown that actually, patients want mutual decision making.

    05:08 This is combining both the patient's previously stated preferences with what the surrogate thinks is in the patient's best interest.

    05:15 So, sort of a shared or mutual decision-making process.

    05:19 That's how the surrogate should make decisions.

    About the Lecture

    The lecture Accuracy of Surrogate Decision Making by Mark Hughes, MD, MA is from the course Surrogate Decision Making and Family Meetings.

    Included Quiz Questions

    1. 50%
    2. 30%
    3. 75%
    4. 10%
    5. 25%
    1. They trust the surrogate's ability.
    2. They trust their relationship with the surrogate.
    3. They feel that the surrogate's judgment may be better than their own.
    4. They are concerned about the physician's best interest.
    5. They trust their relationship with the physician.

    Author of lecture Accuracy of Surrogate Decision Making

     Mark Hughes, MD, MA

    Mark Hughes, MD, MA

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