How to Help Healthcare Surrogates Make a Decision

Research & Resources

Making decisions for patients who are not able to participate in their own decision-making is difficult. As healthcare professionals, we are frequently faced with this situation in the care of elderly patients and those who have suffered a brain injury or stroke and may not be capable of making decisions about their care.

In these situations, we may need to rely on the patient’s healthcare surrogate to help make both clinical and placement decisions. We often underestimate the pressure placed on the surrogate. They may worry that they will cause potential harm by making the wrong decision, and one-third of surrogates have reported lasting psychological effects like depression, anxiety and PTSD.

Why is Being a Surrogate So Difficult?

Surrogates come in all different forms. They may be a spouse, child, grandchild, niece or someone who has been designated with the power of attorney. As a result, their emotional ties to the patient can vary greatly.

We often assume that the surrogate is rational and will clearly digest the clinical information of the medical condition, prognosis and treatment alternatives when we ask the surrogate about the patient’s preferences and values. However, the healthcare surrogate’s emotional state markedly impacts their decision-making. Individuals project their own beliefs and values onto others and their decisions may more closely align with their own preferences rather than the patient’s. Surrogates tend to err on the side of more aggressive therapies that provide “any chance of recovery for the patient.”

How Can You Help Family be a Better Healthcare Surrogate?

Here are four suggestions to improve surrogate decision-making and interactions between the surrogate and your medical team. They all require more time and resources—precious commodities in today’s healthcare environment. It helps to start with family meetings, a time and resource intensive event. However, I truly believe this is a situation of “pay me now or pay me later.” Early Investment in building those relationships will make the tough decisions easier.

  1. Medical information is not enough. The surrogate needs both emotional and psychological support. Find out who provides this service at your facility and offer that as a resource to the patient’s loved ones.
  2. Work to distinguish the surrogate’s own preferences from those of the patient. A question that has served me well for many years is to ask, “If the person could be restored to a normal cognitive and physical state for 15 minutes and look at their current situation, what would they decide?”
  3. When the surrogate is emotionally overwhelmed, pause the treatment decisions and tend to the surrogate’s needs. Palliative care physicians can be very helpful in this situation.
  4. If you sense that the surrogate is primarily projecting their own preferences, they will need to be guided to a more patient-centered approach.

How well prepared are you if you had to be in this situation for a loved one? How would your family handle them? Discuss it now, because remember: “Pay me now or pay me later.”

Resources:

Dionne-Odom JN, White DB. Reconceptualizing how to support surrogates making medical decisions for critically ill patients. JAMA 2021; 325 (21) :2147-2148.