profession

1 in 3 surrogate decision-makers carries lasting emotional burden

A new study finds that advance directives ease stress when making treatment choices for others.

By Kevin B. O’Reilly — Posted March 14, 2011

Print  |   Email  |   Respond  |   Reprints  |   Like Facebook  |   Share Twitter  |   Tweet Linkedin

A third of surrogate decision-makers experience stress, guilt and other upsetting emotions related to their role in determining a loved one's care, according to a March 1 Annals of Internal Medicine systematic review of 40 studies.

The emotional burden on surrogate decision-makers often lasts for months -- and sometimes years -- after the treatment choice, researchers found. One study cited in the review found that stress levels of surrogates were comparable to those of people who experienced construction disasters or lost their homes to fire.

The circumstances of decision-making have an impact on how deeply surrogates are affected, the review showed. Having an advance directive that specifies the patient's wishes substantially reduces surrogates' stress, and achieving consensus with other family members and the care team also helps.

The study offers another reason for doctors and hospitals to encourage patients to complete advance directives, said David Wendler, PhD, lead author of the Annals study.

"We had always thought about documenting your wishes and knowing what the patient wanted as a protection and a benefit for the patient," said Wendler, head of the Unit on Vulnerable Populations at the National Institutes of Health Clinical Center's Dept. of Bioethics. "This study suggests that there is an additional benefit as a protection for the family. Just leaving decisions up to the family may well be counterproductive and make it harder on the family, not easier."

Yet most patients lack advance directives. According to figures cited in a Nov. 3, 2010, commentary in The Journal of the American Medical Association, estimates range from 5% to 25% of the population who have these documents.

"We have to recognize that despite 30 years of asking people to fill out advance directives, it is still a small proportion of the population that has done so," said Daniel P. Sulmasy, MD, who co-wrote the JAMA commentary. "That can't be the total solution to the problem. This new study points us in the direction of looking at better ways of talking to surrogates and better ways of involving the surrogates in the decision-making process that might ameliorate some of the stress."

Physicians should take a more active role in helping surrogates and not shy away from making clinical recommendations, said Dr. Sulmasy, associate director of the University of Chicago's MacLean Center for Clinical Medical Ethics. But first, he said, must come the recognition that being a surrogate decision-maker is no easy task.

"This is not a simple cognitive exercise for the surrogate," Dr. Sulmasy said. "It pays to pay attention to the psychological and even the spiritual needs of surrogates who are making these decisions if we are going to have optimal care for the patient."

Back to top


External links

"Systematic review: the effect on surrogates of making treatment decisions for others," Annals of Internal Medicine, March 1 (link)

"Substituted Interests and Best Judgments: An Integrated Model of Surrogate Decision Making," extract, The Journal of the American Medical Association, Nov. 3, 2010 (link)

Back to top


ADVERTISEMENT

ADVERTISE HERE


Featured
Read story

Confronting bias against obese patients

Medical educators are starting to raise awareness about how weight-related stigma can impair patient-physician communication and the treatment of obesity. Read story


Read story

Goodbye

American Medical News is ceasing publication after 55 years of serving physicians by keeping them informed of their rapidly changing profession. Read story


Read story

Policing medical practice employees after work

Doctors can try to regulate staff actions outside the office, but they must watch what they try to stamp out and how they do it. Read story


Read story

Diabetes prevention: Set on a course for lifestyle change

The YMCA's evidence-based program is helping prediabetic patients eat right, get active and lose weight. Read story


Read story

Medicaid's muddled preventive care picture

The health system reform law promises no-cost coverage of a lengthy list of screenings and other prevention services, but some beneficiaries still might miss out. Read story


Read story

How to get tax breaks for your medical practice

Federal, state and local governments offer doctors incentives because practices are recognized as economic engines. But physicians must know how and where to find them. Read story


Read story

Advance pay ACOs: A down payment on Medicare's future

Accountable care organizations that pay doctors up-front bring practice improvements, but it's unclear yet if program actuaries will see a return on investment. Read story


Read story

Physician liability: Your team, your legal risk

When health care team members drop the ball, it's often doctors who end up in court. How can physicians improve such care and avoid risks? Read story