Can We Improve Treatment Decision-Making for Incapacitated Patients?(Report)

When patients cannot make their own treatment decisions, surrogates typically step in to do it for them. Surrogate decision-making is far from ideal, of course, as the surrogate may not know what the patient prefers or what best promotes her interests. One way to improve it would be to arm surrogates with information about what patients in similar circumstances tend to prefer, allowing them to make empirically grounded predictions about what their patient would want. Clinical practice relies on patients to make their own treatment decisions, typically in consultation with a clinician. This approach is intended to respect those who can make decisions (1) but poses a dilemma for incapacitated patients, such as those with advanced Alzheimer disease. This dilemma is widespread. In the United States, approximately half of all decisions regarding life-sustaining treatment for nursing home residents and three-quarters of decisions for hospitalized patients with life-threatening illnesses involve incapacitated patients. (2) These situations pose significant challenges, especially when it is unclear which treatment the patient prefers, and which treatment best promotes the patient’s clinical interests. For example, should clinicians intubate a patient with moderate Alzheimer disease who has no advance directive and develops pneumonia? Current practice in these cases is to rely on the patient’s surrogate to make treatment decisions in consultation with the patient’s clinicians. Patients sometimes designate a surrogate using a durable power of attorney. State statutes identify next-of-kin surrogates for incapacitated patients who did not appoint a surrogate. (3)

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