Surrogate Decision Making in the ICU

Imagine your loved one is very sick in the ICU. So sick that the ICU doctor believes that there is only a very small chance of survival, and even if your loved one survived, he/she would have significant, permanent disability. If you were placed in this position, how would you want to make decisions about continued intensive medical treatments to support his/her life? Would you want to make it on your own? Would you want to share the responsibility for this decision with the ICU doctor? Would you just want the ICU doctor to make the decision for you with our without your opinion?

Now imagine we ask the same questions to surrogate decision makers of critically ill, incapacitated adults. How do you think they would answer? We now have some idea of how thanks to a study authored by Sara Johnson and her colleagues at UCSF and University of Pittsburgh.

The study, currently in press but accessible early online, presented two clinical vignettes to 230 surrogate decision-makers for incapacitated, mechanically ventilated patients at high risk of death. One vignette was based on a decision regarding life support similar to the one described above, and the other was about selection of specific antibiotic agents to treat an infection.

The main results would make the traditional paternalistic doctor cry.  The vast majority of surrogates wanted either the final say (55%) or shared responsibility (40%) over value-sensitive life support decisions. Only 5% wanted the physician to have final control over these decisions (sorry Dr. House). Of note though, if you tally up where people fall in their preferences, 90% of surrogates wanted the opinion of a physician in these decisions. Further multivariate analysis revealed that low levels of trust in their loved one’s physician, male gender, and being a member of a non-catholic religion, were all significantly associated with surrogates’ preference for a higher degree of decisional control for the value-sensitive life support decisions.

The other interesting aspect of this study was that surrogates preferred significantly more control over the value-sensitive life support decision than decisions regarding technical aspects of care like antibiotic choice. Although, there remained a significant minority who wanted some authority in these decisions too.

So what do we do with these results? First, there is wide variability in how surrogates want to make decisions, so clinicians need to ask about decision-making preferences instead of just picking a one-size-fits-all model. Secondly, clinicians need to tell surrogates what their opinions and recommendations are, instead of just giving a deluge of information. Lastly, clinicians need to build trust in order for these recommendations to carry any sway in the decision making process.

by: Eric Widera