Study looks at physician perspectives on surrogate decision making

Aug 18 2008

Family members are often called upon to make medical choices for patients who are unable to do so themselves. Researchers led by Alexia Torke, M.D., of the Indiana University School of Medicine and the Regenstrief Institute, Inc., studied how physicians treating these patients interacted with surrogate decision-makers.

The qualitative study, based on interviews with physicians who described their own recent interactions with surrogate decision makers, is published in the Summer 2008 issue of the Journal of Clinical Ethics. Their findings led the researchers to conclude that physicians' ethical framework for making decisions in which a surrogate is involved is much more complex than previously realized. Although ethicists have traditionally encouraged physicians to focus exclusively on the patient, physicians in the study also considered the surrogate's wishes and interests in their decision making.

"The number of times that a physician will deal with a surrogate decision maker is growing as our population ages and conditions such as Alzheimer's disease become more common. The issue of how physicians interact with surrogates is a very important one. We found that physicians often want to take an active role in determining what is right for a patient and often grapple with the needs of the patient versus those of the surrogate," said Dr. Torke, who is an IU School of Medicine assistant professor of medicine and geriatrics and a Regenstrief research scientist. She is also on the faculty of the IU Center for Aging Research and the Fairbanks Center for Clinical Medical Ethics.

Some physicians encouraged families to consider the patient's prior wishes and to place them ahead of other considerations. One said, "I always think it's important that it's not a decision that the family member or the surrogate is making for themselves but it is a decision that they are making for someone else, based upon their best knowledge of what that person would want."

Another doctor participating in the study told the researchers, "When I feel strongly that the patient's quality of life is really poor then I do feel that it is appropriate for the physician to try and guide the family member toward a decision."

Another felt that sometimes guidance is not enough and said, "If the patient can't make the decision then I discuss it with the family. I sometimes will push the family to do what I think is best for the patient."

Other physicians were willing to base decisions on what the surrogate wanted for the patient, rather than enquiring about what the patient would have wanted. Physicians were also concerned with the surrogate's well-being, including their emotions, but found the surrogate's needs to be less important than patient-centered concerns. One doctor said, "I think family burden is an issue. I don't think it should govern what the final decision is, but I do think it should be addressed."

The study, which is the first to investigate how doctors apply ethical frameworks for patients unable to make decisions, was supported by the Health Resources and Services Administration of the U.S. Department of Heath and Human Services and by the University of Chicago.

In addition to Dr. Torke, authors of the study are Mary Simmerling, Ph.D.; Mark Siegler, M.D.; Danit Kaya, A.B.; and G. Caleb Alexander, M.D., MS, all of the University of Chicago.