Blog | Wednesday, January 22, 2014

QD: News Every Day--Half of hospitalized patients need surrogate decision making

Nearly half of hospitalized older adults need surrogates for at least part of their decision making, with a quarter of them depending entirely upon the surrogates, a study found.

Researchers conducted a prospective, observational study of more than 1,000 hospitalized seniors identified by their physicians as requiring major medical decisions while staying for longer than 48 hours in the medical and ICU units of 2 hospitals.

Results were published Jan. 20 in JAMA Internal Medicine.

While hospitalized, 47.4% (95% CI, 44.4% to 50.4%) of older adults required at least some surrogate involvement, with 24.4% (95% CI, 21.9% to 27.0%) making joint decisions between the patient and surrogate and 23% (95% CI, 20.6% to 25.6%) requiring all decisions made by a surrogate.

In the ICU, surrogate decision making was even more common. Surrogate involvement occurred in 71.1% (95% CI, 63.8% to 77.5%) of cases, with 27.7% (95% CI, 21.5% to 35%) of patients making joint decisions and 43.4% (95% CI, 36.1% to 51%) requiring all decisions made by a surrogate.

Among patients who required a surrogate for at least 1 decision, 57.2% required decisions about life-sustaining care (mostly addressing code status), 48.6% about procedures and operations, and 46.9% about discharge planning.

Patients who needed a surrogate required greater use of:
• ventilators (2.5% of patients who made decisions and 13.2% of patients who required any surrogate decisions; P <0 .001),
• artificial nutrition (1.7% of patients and 14.4% of surrogates; P <0 .001),
• length of stay (median, 6 days for patients and 7 days for surrogates; P < 0.001), and
• discharge to an extended-care facility (21.2% with patient decisions and 40.9% with surrogate decisions; P <0 .001).

Patients who needed a surrogate also had higher hospital mortality (0.0% patients and 5.9% surrogates; P <0 .001).

Most surrogates were daughters (58.9%), sons (25%), or spouses (20.6%). Only 7.4% of patients had a living will and 25% had a health care representative documented in the medical record.

Researchers noted that early family meetings in the ICU or giving families increased time to speak during the meetings should be built into the hospital structure as a central element of good patient care.

“In the hospital, family members are considered ‘visitors’ rather than crucial participants in their family member’s care,” the authors wrote. “In-depth interviews with surrogates conducted as part of the current study found that surrogates often have trouble contacting hospital staff and struggle for information about the patient. Clinicians also frequently report making decisions with surrogates to be highly stressful.”