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Physicians Consider Patient Preferences -- and Other Issues-- When Making Care Decisions for Patients Unable to Do So Themselves

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Sometimes hospitalized patients are unable to make decisions about their medical care. They may be unable to do so because they are seriously ill, have dementia, or are taking medications that interfere with decision-making, for example.

To prepare for these situations, people can write an "advance directive" that explains what kind of care they do and don't want if they become ill or are injured and can't make their own medical care decisions. There are two basic types of advance directives: those that spell out what kind of medical care a person wants if he or she is unable to make medical decisions; those that name a person who can make these decisions for the person if he or she is able to do so.

In cases where a patient is unable to make his or her own medical decisions and does not have an advance directive, his or her healthcare professional - working with the patient's loved ones, if possible -- have to make "surrogate" medical decisions for him or her.

There are widely accepted "standard ethical guidelines" for surrogate decision making in these situations. These standards stress the importance of the patient's preferences when surrogate medical decisions must be made. When the patient's wishes are completely unknown, widely accepted guidelines emphasize that decisions should be based on what is best for the patient.

New Research in the Journal of the American Geriatrics Society
To learn more about how physicians make surrogate medical decisions for hospitalized adults who are unable to make decisions on their own, researchers surveyed nearly 300 physicians at three large hospitals in a major US city.

The researchers gave the physicians surveys asking what principles, or standards, should guide surrogate medical decision-making. The surveys also asked if the doctors if they had recently made a surrogate decision for a hospitalized patient. If they had, they were asked to describe a patient for whom they'd recently made a surrogate decision, and what they considered when making that decision.

Nearly 75% of the physicians surveyed said that "patient preferences" were, in general, the "most important" thing to consider when making surrogate medical decisions. And 73% of the physicians surveyed reported that they had recently made such a decision for a hospitalized adult. But of these physicians, only 29% reported that patient preferences were, in fact, the "most important" factor in their recent decisions. The vast majority of these physicians said that patient preferences were "highly important" but not "most important" in the surrogate medical decisions they'd actually made. Other considerations, including what was best for the patient, appeared to be just as, if not more, important.

"These findings don't mean that physicians aren't familiar with standard ethical guidelines for surrogate decision making," the researchers report in the Journal of the American Geriatrics Society. And they don't mean that physicians ignore patient preferences, the researchers add.

In many of the cases the physicians described, information about the patient's preferences wasn't available because the patient did not have an advance directive, and hadn't told anyone about his or her care preferences. In other cases, the patient hadwritten an advance directive or talked about his or her preferences -- but only in situations that were different from the one in which the patient found himself or herself. In still other cases, the patient had had major changes in his or her health since writing an advance directive or discussing his or her care preferences – changes that might have led him or her to change these preferences. In such circumstances, the researchers note, the physicians involved may have decided that doing what was best for the patient was at least as important as considering his or her preferences, the researchers report.

"In conclusion, although widely accepted models of surrogate decision making rank patient preferences as the most important ethical guideline for surrogate decision making and a majority of ... physicians identify this as the most important guideline, physicians rely on a variety of factors when making decisions in the hospital setting," the researchers conclude. "Even when helpful information about the patient's preferences is available, physicians appear to incorporate other decision-making factors that may be at least equally important. This difference between ethical theory and physician practice could encourage us either to compel physicians to weigh patient preferences more heavily in surrogate decision making or to consider whether the ethical framework for surrogate decisions should be modified to allow for balancing of multiple decision-making factors."

According to the researchers, other studies have found that patients do, in fact, want physicians and family members to have some leeway in medical decision making.

The summary above is from the full report titled, "Physicians' Views on the Importance of Patient Preferences in Surrogate Decision Making." It is in the March 2010 issue of the Journal of the American Geriatrics Society (Volume 59, Issue 3). The report is authored by Alexia M. Torke, MD, MS, Rachael Moloney, BA, Mark Siegler, MD, Anna Abalos, MD, and G. Caleb Alexander, MD, MS.