Recommendations of Physicians are Critical to End-of-Life Decision-Making for Surrogates

Recent Hesitation

Given the aging population in America along with the technological advances in life-sustaining interventions and treatments, several patients will be incapacitated when there is a need for complex end-of-life treatment decisions to be made.  According to experts from The University of Chicago Department of Medicine, the recent emphasis on family-centered care does not change the integral fact that physician recommendations directly influence the decision-making processes of patients’ surrogates.  

According to an article published in the Journal of Pain and Symptom Management, “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.”

Although patients have traditionally expected physicians to make recommendations for medical care at the end of life, current concepts of patient independence and surrogate responsibility may have blurred the lines of the issue for some. Recently a trend has arisen where physicians hesitate in making recommendations, out of their concern that they will be considered patronizing.  Additionally, some physicians are not sure if recommendations at the end of life would be openly welcomed by surrogate decision-makers, or if their recommendations are truly an aspect of good shared decision-making.

Evidence

The researchers in the aforementioned study reviewed the empirical evidence from six quantitative studies regarding surrogate and patient preferences surrounding physician recommendations for end-of-life care.  They then evaluated the ethical case for integrating physician recommendations into the care decisions for terminally ill and incapacitated patients.

The researchers concluded that “all [choices] require that the physician communicate an opinion about a medical decision, which is to make a recommendation,” regardless of whether the surrogates and/or patients expressed their preference for who makes the final decision(s).  They reviewed that only 0 – 1.2% of surrogates preferred to make the decision alone.  The data demonstrated that not only did patients prefer surrogates to know their physician’s opinion treatment at the end of life, but most surrogates preferred to be aware of it as well.

With the family-centered approach to end-of-life care, shared decision-making is included, but does not mean that physicians will abdicate the responsibility for medical decisions to surrogates.  Instead, the article explains that shared decision-making allows for a collaborative exchange in which practitioners are able to help families navigate the predictive uncertainty of complicated medical circumstances and life-sustaining options. Surrogates offer their unique knowledge and understanding of their loved one’s values and desires.

Challenges

Shared end-of-lidfe decision-making, however, does constitute possible difficulties that the researchers have identified as the following:

• Prognostication itself can be difficult
• Explaining clinical uncertainty and complicated clinical situations with conciseness and clarity is a further challenge
• Surrogates are often at risk for post-traumatic stress disorder, and therefore, physicians may hesitate to offer their perspective, in an effort to proceed cautiously

The Ethics

With regard to ethics, having a physician’s recommendations included in end-of-life decision-making is justified.  It represents the ideals of independence such as the surrogate having the autonomy to accept or decline the physician’s recommendation, maintaining medical best practices, and contributing to the relationship between the patient and physician.  Furthermore, the researchers conclude that physician recommendations should continue to be the norm for practice in end-of-life shared decision-making with surrogates, as opposed to a lack of evidence or even morally persuasive arguments. 

References

Prochaska, M. T. & Sulmasy, D. P. (2015). 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, 50 (5), 693-700. https://doi.org/10.1016/j.jpainsymman.2015.05.004