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Original Investigation |

Scope and Outcomes of Surrogate Decision Making Among Hospitalized Older Adults

Alexia M. Torke, MD1,2,3,4; Greg A. Sachs, MD1,2,3; Paul R. Helft, MD4,5; Kianna Montz, MA1,2; Siu L. Hui, PhD1,2,6; James E. Slaven, MS6; Christopher M. Callahan, MD1,2,3
[+] Author Affiliations
1Indiana University Center for Aging Research, Indianapolis
2Regenstrief Institute, Inc, Indianapolis, Indiana
3Division of General Internal Medicine and Geriatrics, Indiana University, Indianapolis
4Fairbanks Center for Medical Ethics, Indiana University Health, Indianapolis
5Melvin and Bren Simon Cancer Center, Indiana University, Indianapolis
6Department of Biostatistics, Indiana University, Indianapolis
JAMA Intern Med. 2014;174(3):370-377. doi:10.1001/jamainternmed.2013.13315.
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Importance  Hospitalized older adults often lack decisional capacity, but outside of the intensive care unit and end-of-life care settings, little is known about the frequency of decision making by family members or other surrogates or its implications for hospital care.

Objective  To describe the scope of surrogate decision making, the hospital course, and outcomes for older adults.

Design, Setting, and Participants  Prospective, observational study conducted in medicine and medical intensive care unit services of 2 hospitals in 1 Midwestern city in 1083 hospitalized older adults identified by their physicians as requiring major medical decisions.

Main Outcomes and Measures  Clinical characteristics, hospital outcomes, nature of major medical decisions, and surrogate involvement.

Results  According to physician reports, at 48 hours of hospitalization, 47.4% (95% CI, 44.4%-50.4%) of older adults required at least some surrogate involvement, including 23.0% (20.6%-25.6%) with all decisions made by a surrogate. Among patients who required a surrogate for at least 1 decision within 48 hours, 57.2% required decisions about life-sustaining care (mostly addressing code status), 48.6% about procedures and operations, and 46.9% about discharge planning. Patients who needed a surrogate experienced a more complex hospital course with greater use of ventilators (2.5% of patients who made decisions and 13.2% of patients who required any surrogate decisions; P < .001), artificial nutrition (1.7% of patients and 14.4% of surrogates; P < .001), and length of stay (median, 6 days for patients and 7 days for surrogates; P < .001). They were more likely to be discharged to an extended-care facility (21.2% with patient decisions and 40.9% with surrogate decisions; P < .001) and had higher hospital mortality (0.0% patients and 5.9% surrogates; P < .001). Most surrogates were daughters (58.9%), sons (25.0%), or spouses (20.6%). Overall, only 7.4% had a living will and 25.0% had a health care representative document in the medical record.

Conclusions and Relevance  Surrogate decision making occurs for nearly half of hospitalized older adults and includes both complete decision making by the surrogate and joint decision making by the patient and surrogate. Surrogates commonly face a broad range of decisions in the intensive care unit and the hospital ward setting. Hospital functions should be redesigned to account for the large and growing role of surrogates, supporting them as they make health care decisions.

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Figure 1.
Enrollment of Study Participants

Flow diagram includes admission notifications for all patients 65 years and older admitted during the study period and indicates enrollment based on whether the patient required a surrogate decision maker, made decisions jointly with a surrogate, or made decisions independently.

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Figure 2.
Percentage of Patients Requiring Surrogate Decision Making, by Admission Location

ICU indicates intensive care unit.

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