Half of hospitalized adults over 65 need surrogate decision-makers, study finds

Nearly half of hospitalized American adults age 65 and older require decision-making assistance from family members or other surrogates because the patient is too impaired to make decisions independently, according to a new study from the Regenstrief Institute and the Indiana University Center for Aging Research. The vast majority of surrogates are children or spouses, and some patients have two or more family member making decisions together.

More than 13 million are hospitalized annually in the United States, and that number is projected to increase as the population ages. This means that each year, millions of family members will have to make serious decisions for a hospitalized older adult.

Surrogates will commonly face decisions about life-sustaining care, such as whether to revive a loved one if his or her heart were to stop, as well as decisions about medical procedures and whether to send the patient to a nursing facility upon discharge.

"As the population ages, family members of older adults should prepare for the crucial role they may play when their loved ones are hospitalized," said Regenstrief Institute investigator Alexia Torke, M.D., M.S., associate professor of medicine at Indiana University School of Medicine, who led the study.

A higher proportion of needed surrogate decision-making, but the majority of patients in the study who required a surrogate were admitted to the general medicine wards, suggesting that families are needed to make decisions throughout the hospital.

"Scope and Outcomes of Surrogate Decision-Making Among Hospitalized Older Adults" was published online Jan. 20 in advance of print publication in the March 2014 issue of JAMA Internal Medicine.

Before this study, little was known about the frequency and scope of decision-making by family members or other according to Dr. Torke. The investigators followed 1,083 hospitalized older adults in either a medical intensive care unit or on the medical service of two large urban hospitals. The care of all patients required major medical decisions.

When patients cannot make decisions for themselves due to dementia, delirium or other types of cognitive impairment, physicians turn to surrogate decision-makers, most commonly a close family member. In some instances, a surrogate may have been previously designated by the patient who completed a Health Care Power of Attorney form, but in many cases the individual is not fully informed about the patient's wishes. Surrogates are asked to make decisions in critical areas including code status, ventilators and other life-prolonging therapies, surgery options, and post-hospital placement. All are vital to the patient's care and outcome.

The presence of a surrogate requires fundamental changes in the way clinicians communicate and make decisions for patient, according to the study authors. They call for redesign of hospital functions to account for the large and growing role of surrogates and to provide support for surrogates as they make health care decisions.

"Many hospitals treat as visitors rather than as members of the patient's health care team," Dr. Torke said. "In-depth interviews with surrogates conducted as part of my ongoing research has found that surrogates often have trouble contacting hospital staff and struggle for information about the patient. Clinicians also frequently report making decisions with surrogates to be highly stressful."

Two-thirds of the patients in the study were female, and half were African-American. Patients in the study who needed surrogate involvement were more seriously ill compared to those who made decisions on their own, due to the relationship between serious illness and changes in mental status for older adults, Dr. Torke said. Such had a more complex hospital course, longer lengths of stay and higher mortality. They were also more likely to go to a nursing home or other rehabilitation facility upon hospital discharge.

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