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Making the Rounds

Physician Recommendations to Surrogates Crucial to Decision Making near Life’s End, Experts Conclude

01/14/2016

Physician Recommendations

Recent Hesitation

With the aging of the American population and continuing technological advances in life-sustaining interventions, many patients will be incapacitated when complex end-of-life treatment decisions are called for. Recent emphasis on family-centered care in no way changes the integral part that physician recommendations play in sharing decision making with patients’ surrogates, according to experts from The University of Chicago Department of Medicine.

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“Both the available data and good ethics suggest that physicians should make recommendations to surrogates regarding end-of-life medical decisions for their loved ones as part of the dynamic and interactive process of shared decision making,” write the authors of a special article published in the Journal of Pain and Symptom Management.

Patients have traditionally expected physicians to make recommendations for medical care at the end of life, note the authors. But current concepts of patient autonomy and surrogate responsibility may have clouded the issue for some. There has been a recent trend for physicians to hesitate in making recommendations, out of concern of appearing paternalistic. In addition, some physicians may wonder if recommendations at the end of life would even be welcomed by surrogates or are truly a part of good shared decision making.

The Evidence

The team reviewed the empirical evidence from six recent quantitative studies on surrogate and patient preferences for physician recommendations regarding end-of-life care. They then assessed the ethical arguments for incorporating physician recommendations into care decisions for terminally ill, incapacitated patients.

Whether surrogates and/or patients reported a preference for the physician to make the final decision, for making the decision jointly with the physician or for making it themselves after considering the physician’s opinion, “all [choices] require that the physician communicate an opinion about a medical decision, which is to make a recommendation,” the authors observe. In the studies they reviewed, zero to 1.2% of surrogates said they preferred to make the decision alone.

“Careful examination of these studies and the available data demonstrates that patients prefer surrogates to know, and most surrogate decision makers themselves prefer to know, the opinion of the physician regarding treatment options at the end of life,” write the authors.

The family-centered approach to end-of-life care, which includes shared decision making, does not mean that physicians relinquish responsibility for medical decisions to the family or surrogate. Rather, “shared decision making fosters a collaborative exchange in which clinicians help families navigate the prognostic uncertainty of complex medical conditions and life-sustaining technologies,” while surrogates share their unique knowledge and understanding of the patient’s values and wishes.

Challenges

However, the authors identify possible difficulties in shared end-of-life decision making, such as the following:

  • Prognostication itself can be formidable.
  • Explaining clinical uncertainty and complex clinical circumstances with clarity is a further challenge.
  • Surrogates are often at risk for post-traumatic stress disorder, and physicians may hesitate to offer opinions, wanting to tread carefully.

The Ethics

Ethically, end-of-life decision making that incorporates a physician’s recommendations is justified because it “embodies our ideals of autonomy (the surrogate is free to accept or decline the physician’s recommendation), good medical practice and the patient-physician relationship,” write the authors.

“The opinion of the physician is a critical piece of data to which surrogates should not be denied access if they are to arrive at the best decision for the patient,” write the authors. “[A]bsent evidence or morally persuasive arguments to the contrary, physician recommendations should continue to be the norm for practice in shared decision making with surrogates.”

Source: “Recommendations to Surrogates at the End of Life: A Critical Narrative Review of the Empirical Literature and a Normative Analysis,” Journal of Pain and Symptom Management; November 2015; 50(5):693-700. Prochaska MT; Sulmasy DP; Department of Medicine; MacLean Center for Clinical and Medical Ethics, The University of Chicago, Chicago.