Search out the surrogates

Sharing decision making has become a widely accepted tenet of medical practice. But applying the concept can be tricky, especially for elderly inpatients, whose care requires decisions that they are unable to make on their own due to conditions like delirium and dementia.

To better quantify this challenge of hospital practice, researchers at 2 hospitals in Indianapolis recently studied about 1,000 medical inpatients over age 65 who were faced with major decisions during hospitalization. Among other factors, they looked at the involvement of surrogate decision makers in the patients' care and found that it was both more common and more complicated than one might expect. The study was published online by JAMA Internal Medicine in March.

Lead study author Alexia M. Torke, MD, recently spoke with ACP Hospitalist about the implications of her research for hospitals and hospitalists. She is an associate professor of medicine at the Indiana University School of Medicine in Indianapolis.

Q: What motivated you to study surrogate decision making?

A: We've known for a long time that surrogate decision making can be very stressful for family members, even leading to symptoms of posttraumatic stress disorder. Some of my prior research has shown that it's even very stressful for clinicians, and there's evidence there are serious problems with communication. The bottom line is that it's hard enough for patients to make serious health decisions for themselves, but it's even harder to make decisions for somebody else. We wanted to ask the question, “How often is [surrogate decision making] needed?”

Q: What did you find?

A: Our main finding was that, among adults 65 and older, nearly half of them need assistance with decision making in the first 48 hours [of hospitalization]. I was surprised by how common it was. We have a concept of the norm in decision making in the hospital being the independent patient who can give a history and make their own decisions and talk with clinicians. It turns out that, for older adults, surrogate decision making is almost as common as patient decision making.

Q: How should your findings affect hospitalist practice?

A: For older adults, we need to have the family on our mind right from the start. With every patient, it's important to ask, “What role does the family need to play in decision making?” For hospital patients who can make decisions independently, they retain the right to make autonomous decisions and it's their choice how much they involve the family, but we should be asking this question much earlier in the hospital process, in fact, right from admission.

Q: What changes could be made to facilitate surrogate decision making?

A: It should be standard to call family members on a regular basis, perhaps even a daily basis in many cases, just to update them about the patient's condition and then discuss potential decisions. We need to think about structuring hospital rounds around availability of the family. There's the opportunity to include family more intentionally and more coherently in the process of decision making.

Q: While almost half of patients had some surrogate decision making, only 23% had all their decisions made by a surrogate. How does that finding affect care?

A: That was a surprising finding of our study. A substantial percentage of patients who need surrogate input actually had some kind of combined decision making. The patients could communicate and be part of the decision-making process, even though the physicians didn't think they were able to make decisions independently. That kind of communication with a patient and family member and clinicians is even more complicated. Physicians need focused training on how to include family members in a discussion when the patient is still participating.

Q: Your study found that only 7.4% of the patients had a living will and 25% had designated a health care representative. Should improving these statistics be a focus of improvement, too?

A: Advance directives are definitely part of the issue. I, in my practice, encourage patients to name a health care representative or power of attorney for health care. That should be done earlier rather than later.