Patient and surrogate disagreement in end-of-life decisions: Can surrogates accurately predict patients' preferences?

Background. When a patient is too incapacitated to make important end-of-life decisions, doctors may ask a preappointed surrogate to predict the patient's preferences and make decisions on the patient's behalf. The current study investigates whether surrogates project their own views onto what they predict the patients' preferences are. Methods. Using data from seriously ill patients and their surrogates, the authors created a "projection" variable that addresses the following question: When surrogates are asked to predict a patient's end-of-life preferences, do they mistakenly replace this prediction with what they would want the patient to do? The authors examined the 144 patient-surrogate pairs in which surrogates inaccurately predicted patients' CPR (cardiopulmonary resuscitation) v. DNR (do not resuscitate) decisions and the 294 pairs in which surrogates inaccurately predicted patients' extend life v. relieve pain preferences. Among these patient-surrogate pairs, the authors determined the extent to which surrogates' wishes for the patient matched their incorrect predictions of what the patient wanted. Results. Of the patient-surrogate pairs who disagreed on CPR v. DNR and extend life v. relieve pain preferences, 62.5% and 88.4% of surrogates demonstrated projection for CPR v. DNR decisions and extend life v. relieve pain preferences, respectively. Age-related and demographic variables did not predict cases in which projection did and did not occur. Conclusion. When surrogates inaccurately predict the CPR v. DNR and extend life v. relieve pain preferences of seriously ill, hospitalized loved ones, surrogates' prediction errors often represent surrogates' own wishes for the patient.