Facilitating Surrogate Decision Making

by Mark Hughes, MD, MA

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    00:02 What can clinicians do to help surrogates with the decision-making process? First and foremost thing is they have to establish and maintain trust.

    00:12 They have to be trustworthy in how they're communicating with the surrogate.

    00:16 So, there's a certain amount of reciprocity in that relationship.

    00:20 So, the give and take of communication, you're as a clinical, sharing information with the surrogate.

    00:27 You want to get information back from them. You want to show that it's a trustworthy process that you're going to really rely on them to speak on the best interest of the patient.

    00:38 If you've made any particular treatment plans, if there's been any kind of negotiation in figuring out, you know, shared decision-making of what you're going to do, that you keep those agreements, you follow through on the plan that you've arranged with the surrogate decision maker.

    00:53 If it's difficult information similar to what we do with patients in breaking serious or difficult news, we're going to share information with the surrogate decision maker honestly attending to their emotions, making sure they really are able to handle that information.

    01:12 Whenever we speak with surrogate decisions makers, we should make sure we're going in with the proper intention that we speak with good purpose.

    01:18 We take the seriousness of the situation and we, you know, really help that surrogate decision maker with their decision-making. And always, we should be showing respect for that person.

    01:30 It's a difficult situation to be in, so, we show them respect in our communication with them, again, to make sure we're establishing and maintaining trust with them.

    01:42 We need to meet their emotional needs. You know, they're going to be seeing their loved ones sick.

    01:48 They're going to have emotional reactions to that.

    01:50 So, we have to provide the empathetic response to what they're going through.

    01:56 They may have spiritual needs as well that we also have to attend to, either ourselves as the clinicians or inviting other members of the healthcare team, a chaplain or other, you know, faith or spiritual adviser to help with the surrogate's spiritual needs as they're serving this role as a decision maker. And lastly, it's, you know, an ongoing process.

    02:18 So, we want to help them be confident in their role as a surrogate decision maker.

    02:23 We want to build their self-efficacy for being a decision maker.

    02:27 So, that's also talking to them about what to expect, what decisions they might need to make in the future, knowing what their role is, what they need to do, you know, do you need to go home and talk to other family members and weigh the information we've given you and then, come back tomorrow and we'll make a decision? They need to sort of have clear expectations of what their role requires.

    02:53 When you have actual meetings with surrogate decision makers, there are a few steps that you should keep in mind.

    02:58 You should first of all just say, this is something that we do with all family members when a patient can't make their own decisions. You want to normalize the process.

    03:06 It's, you know, common for us to meet with family to help them think through the issues and come up with decisions for their loved one.

    03:16 You want to acknowledge that it's difficult to be a surrogate decision maker.

    03:19 You know, it' hard for you to be put in this role.

    03:22 We know it's, you know, sometimes requires some interpretation of the patient's previous wishes or what they've put in advanced directive, acknowledge that difficulty and say, again, tryng to do the best you can, so, we can serve the patient's best interest.

    03:38 You want to show compassion for the surrogate in seeing their loved one ill.

    03:42 So, helping them cope with what's going on, coping with the situation.

    03:46 For instance, in the intensive care unit, we often see family members who are distraught or very anxious. They don't sleep.

    03:55 They stay in the hospital all the time. We need to make sure that they are taken care of themselves, so, that they can then, you know, be the surrogate decision maker for their loved one.

    04:05 You want to put the decision-making process in the context of a team.

    04:11 So, you want to say, "We're the team helping you make decisions but you're also a team member.

    04:17 We're all trying to do this together on behalf of the patient." So, making sure that they're aware that they've got that support of the rest of the team in this context.

    04:28 And then, again, the whole goal of this is we really want to try to understand the patient's previously expressed values, goals, beliefs, who they were as a person, who they are as a person.

    04:41 And then, let the surrogate make decisions, give them the recommendations, but then, make the decisions based on their knowledge of the patient.

    About the Lecture

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

    Included Quiz Questions

    1. Commanding authority
    2. Creating trustworthiness
    3. Negotiating and keeping arrangements
    4. Sharing information honestly
    5. Speaking with good purpose
    1. Show compassion.
    2. Place the decision-making process in the context of a team.
    3. Provide recommendations based on the patient's values, goals, and beliefs.
    4. Demand respect.
    5. Demonstrate power.

    Author of lecture Facilitating Surrogate Decision Making

     Mark Hughes, MD, MA

    Mark Hughes, MD, MA

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