Physicians' Experience with Surrogate Decision Making for Hospitalized Adults

BACKGROUND: Hospitalized patients frequently lack decision-making ability, yet little is known about physicians' approaches to surrogate decision making. OBJECTIVE: To describe physicians' experiences with surrogate communication and decision making for hospitalized adults. DESIGN: Cross-sectional written survey. PARTICIPANTS: Two hundred eighty-one physicians who recently cared for adult inpatients in one academic and two community hospitals. MEASUREMENTS: Key features of physicians' most recent surrogate decision-making experience, including the nature of the decision, the physician's reaction, physician-surrogate communication and physician-surrogate agreement about the best course of action. RESULTS: Nearly three fourths of physicians (73%, n=206) had made a major decision with a surrogate during the past month. Although nearly all patients (90%) had a surrogate, physicians reported trouble contacting the surrogate in 21% of cases. Conflict was rare (5%), and a majority of physicians agreed with surrogates about the medical facts (77%), prognosis (72%) and best course of action (65%). After adjustment for patient, physician and decision characteristics, agreement about the best course of action was more common among surrogates for older patients [prevalence ratio (PR) = 1.17 for each decade; 95% confidence interval (CI) 1.02-1.31], ICU patients (PR=1.40; CI 1.14-1.51) and patients who had previously discussed their wishes (PR=1.60; CI 1.30-1.76), and less common when surrogates were difficult to contact (PR=0.59; CI 0.29-0.92) or when the physician self-identified as Asian (PR=0.60; CI 0.30-0.94). CONCLUSION: Surrogate decision making is common among hospitalized adults. Physician-surrogate decision making may be enhanced if patients discuss their preferences in advance and if physician contact with surrogate decision makers is facilitated.