Patient preferences are important when making clinical decisions for those who can't, but other factors also play a role
Research Activities, August 2010, No. 360
Hospitalized patients may not be able to make important medical decisions for themselves for a variety of reasons. They may be unconscious, heavily sedated, or experiencing other factors that render them incapable of decisionmaking. In such cases, physicians are called upon as surrogates to make difficult decisions based on the patient's prior stated wishes and other factors. A recent study suggests that, while patient preferences are important, physicians also use other information to make appropriate treatment decisions.
Researchers surveyed 281 attending and resident physicians from an academic medical center and two community hospitals (one Catholic). All were asked if they had made any major decisions for incapacitated patients, details about the situation, and how they came up with their decision. They were also asked to rate a series of potential factors in order of importance based on their decision for a particular patient. These included such things as the patient's prognosis, the level of pain and suffering, legal ramifications, and family burden.
Nearly three-fourths of the physicians (73.3 percent) reported having to make a surrogate decision recently. When asked to identify the most important ethical standard for surrogate decisionmaking, the majority of physicians chose a standard based on the patient's own preferences. For example, 61.2 percent cited written advance directives and 11.4 cited substituted judgment, which involves determining what the patient would have wanted. When making decisions for their most recent patient, a great majority (81.8 percent) felt the patient's own preferences were very important considerations in the decisionmaking process. However, only 29.4 percent considered the patient's preferences to be the most important factor.
Decisions were most often likely based on patient preferences when the patient was in the intensive care unit. These became less important when making decisions for older patients. No association was found between relying on patient preferences and the physician's beliefs about ethical principles guiding surrogate decisionmaking or whether the patient had expressed such preferences through a living will or earlier discussions. The study was supported in part by the Agency for Healthcare Research and Quality (HS15699).
See "Physicians' views on the importance of patient preferences in surrogate decision-making," by Alexia M. Torke, M.D., M.S., Rachael Moloney, B.A., Mark Siegler, M.D., and others in the March 2010 Journal of the American Geriatrics Society 58(3), pp. 533-538.