Improving Communication With Surrogate Decision-Makers: A Pilot Initiative

ABSTRACT Background Difficult conversations in medical care often occur between physicians and patients' surrogates, individuals entrusted with medical decisions for patients who lack the capacity to make them. Poor communication between patients' surrogates and physicians may exacerbate anxiety and guilt for surrogates, and may contribute to physician stress and burnout. Objective This pilot study assesses the effectiveness of an experiential learning workshop that was conducted in a clinical setting, and aimed at improving resident physician communication skills with a focus on surrogate decision-making. Methods From April through June 2016, we assessed internal medicine residents' baseline communication skills through an objective structured clinical examination (OSCE) with actors representing standardized surrogates. After an intensive, 6-hour communication skills workshop, residents were reassessed via an OSCE on the same day. A faculty facilitator and the surrogate evaluated participants' communication skills via the expanded Gap Kalamazoo Consensus Statement Assessment Form. Wilcoxon signed rank tests (α of .05) compared mean pre- and postworkshop scores. Results Of 44 residents, 33 (75%) participated. Participants' average preworkshop OSCE scores (M = 3.3, SD = 0.9) were significantly lower than postworkshop scores (M = 4.3; SD = 0.8; Z = 4.193; P < .001; effect size r = 0.52). After the workshop, the majority of participants self-reported feeling “more confident.” Conclusions Residents' communication skills specific to surrogate decision-making benefit from focused interventions. Our pilot assessment of a workshop showed promise, and additionally demonstrated the feasibility of bringing OSCEs and simulated encounters into a busy clinical practice.

Download Full-text

Financial Surrogate Decision Making: Lessons from Applied Experimental Philosophy

The Spanish Journal of Psychology ◽

10.1017/sjp.2016.54 ◽

2016 ◽

Vol 19 ◽

Cited By ~ 1

Author(s):

Adam Feltz

Keyword(s):

Decision Making ◽

Experimental Philosophy ◽

Decision Makers ◽

Surrogate Decision Making ◽

Financial Decisions ◽

Financial Decision Making ◽

Recent Debate ◽

Surrogate Decision Makers ◽

Financial Decision ◽

Surrogate Decision

AbstractAn estimated 1 in 4 elderly Americans need a surrogate to make decisions at least once in their lives. With an aging population, that number is almost certainly going to increase. This paper focuses onfinancialsurrogate decision making. To illustrate some of the empirical and moral implications associated with financial surrogate decision making, two experiments suggest that default choice settings can predictably influence some surrogate financial decision making. Experiment 1 suggested that when making hypothetical financial decisions, surrogates tended to stay with default settings (OR = 4.37, 95% CI 1.52, 12.48). Experiment 2 replicated and extended this finding suggesting that in a different context (OR = 2.27, 95% CI 1.1, 4.65). Experiment 2 also suggested that those who were more numerate were less likely to be influenced by default settings than the less numerate, but only when the decision is whether to “opt in” (p= .05). These data highlight the importance of a recent debate about “nudging.” Defaults are common methods to nudge people to make desirable choices while allowing the liberty to choose otherwise. Some of the ethics of using default settings to nudge surrogate decision makers are discussed.

Download Full-text

The judgment grounds in surrogate decision-making in Japanese clinical practice: A qualitative survey

10.21203/rs.3.rs-24105/v1 ◽

2020 ◽

Author(s):

Masashi Tanaka ◽

Kayoko Ohnishi ◽

Aya Enzo ◽

Taketoshi Okita ◽

Atsushi Asai

Keyword(s):

Decision Making ◽

Clinical Practice ◽

Decision Makers ◽

Best Interests ◽

Current Status ◽

Surrogate Decision Making ◽

Surrogate Decision Makers ◽

Surrogate Decision ◽

Family Preference ◽

Made In

Abstract Background Surrogate decision-making is expected to become more prevalent in Japanese clinical practice. In recent years, activities to promote advanced care planning (ACP) have gathered momentum ,which may potentially affect the ways in which judgments are made in surrogate decision-making. The purpose of this study is to clarify the current judgment grounds on which surrogate decisions are made in Japan. Methods We adopted a qualitative research method that was based on semi-structured interviews to reveal the judgement grounds in surrogate decision-making involving critical, life-related choices in acute hospitals. Results We interviewed 15 participants. We analyzed the content of the 14 transcribed texts, eliminating one text that does not meet the inclusion criteria. We extracted a total of 4 core categories, 17 categories, 35 subcategories, and 55 codes as an analysis results of interviews regarding the judgment grounds in surrogate decision-making. The four categories are as follows: type 1“Patient preference-oriented factor”, type2“Patient interest-oriented factor”, type3“Family preference-oriented factor”,and type4 “Balanced patient/family preference-oriented factor”. Conclusions This study revealed the current status of surrogate decision-making in Japan: when making decisions about important matters related to a patient’s life, surrogate decision-makers base their decisions not only on the preferences and best interests of the patient, but on their own preferences as well. Included in the preferences of surrogate decision-makers were their own views of life and death, their values, and care burden. Given the cultural and social backgrounds in Japan, it remains unclear whether ACP can be properly reflected in judgment grounds in surrogate decision-making. It would be undesirable to base judgments solely on the principle of respect for autonomy or the principles of surrogate decision-making. In the future, we believe that surrogate decisions-makers will be required to consider the judgment grounds from a more diverse perspective and that such attitudes should be ethically accepted.

Download Full-text

Grounds for surrogate decision-making in Japanese clinical practice: a qualitative survey

BMC Medical Ethics ◽

10.1186/s12910-020-00573-4 ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Masashi Tanaka ◽

Kayoko Ohnishi ◽

Aya Enzo ◽

Taketoshi Okita ◽

Atsushi Asai

Keyword(s):

Decision Making ◽

Clinical Practice ◽

Decision Makers ◽

Best Interests ◽

Surrogate Decision Making ◽

Inclusion Criteria ◽

Surrogate Decision Makers ◽

Surrogate Decision ◽

Factor Type ◽

Family Preference

Abstract Background In the coming years, surrogate decision-making is expected to become highly prevalent in Japanese clinical practice. Further, there has been a recent increase in activities promoting advance care planning, which potentially affects the manner in which judgements are made by surrogate decision-makers. This study aims to clarify the grounds on which surrogate decision-makers in Japan base their judgements. Methods In this qualitative study, semi-structured interviews were conducted to examine the judgement grounds in surrogate decision-making for critical life-sustaining treatment choices in acute care hospitals. Results A total of 228 participants satisfied the inclusion criteria, and 15 were selected for interviews. We qualitatively analysed the content of 14 interview transcripts, excluding one that did not meet the inclusion criteria. Based on this analysis, we extracted 4 core categories, 17 categories, 35 subcategories, and 55 codes regarding judgement grounds in surrogate decision-making. The four core categories were as follows: patient preference-oriented factor (Type 1), patient interest-oriented factor (Type 2), family preference-oriented factor (Type 3), and balanced patient/family preference-oriented factor (Type 4). The Type 4 core category represented attempts to balance the preferences of the patient with those of the surrogate decision-maker. Conclusions Surrogate decision-makers based their decisions on important aspects related to a patient’s life, and they considered not only the patient’s preferences and best interests but also their own preferences. As the need for surrogate decisions will increase in the future, decision-makers will need to consider judgement grounds from a more diverse perspective.

Download Full-text

Family and Physicians' Views of Surrogate Decision-Making: The Roles and How to Choose

International Psychogeriatrics ◽

10.1017/s1041610296002906 ◽

1996 ◽

Vol 8 (4) ◽

pp. 589-596 ◽

Cited By ~ 9

Author(s):

Michel Silberfeld ◽

Rivka Grundstein-Amado ◽

Derek Stephens ◽

Raisa Deber

Keyword(s):

Alzheimer’S Disease ◽

Alzheimer's Disease ◽

Decision Making ◽

Shared Decision Making ◽

Family Members ◽

Decision Makers ◽

Surrogate Decision Making ◽

Shared Decision ◽

Surrogate Decision Makers ◽

Surrogate Decision

Physicians and family members were compared on the roles played in surrogate decision-making and their views as to how choices should be made by surrogate decision-makers. Thirty-six family members of patients with Alzheimer's disease, 35 family members of patients with schizophrenia, and 34 physicians from a diversity of specialties were the respondents. There was general agreement that shared decision-making was preferred. Physicians seem to make surrogate decisions in accordance with contemporary views about their roles. Families believed they had a strong subjective appreciation of the patient's overall good. The burden of decision-making was geater for families, but that depended to some degree on the diagnosis of the patient.

Download Full-text

Whose Decision Is This?

Pediatric Palliative Care ◽

10.1093/med/9780190051853.003.0001 ◽

2020 ◽

pp. 3-6

Author(s):

Elissa G. Miller

Keyword(s):

Decision Making ◽

End Of Life ◽

End Of Life Care ◽

Surrogate Decision Making ◽

Life Care ◽

Best Interest ◽

Best Interest Standard ◽

Surrogate Decision Makers ◽

Surrogate Decision ◽

End Of Life Decision

Decision-making in palliative and end-of-life care can be difficult to navigate. This is even more so in pediatric palliative and end of life care when parents may disagree with each other or for teenagers who are not yet legally able to make their own medical decisions. Surrogate decision making can also complicate end of life decision making in pediatrics. To navigate these complex situations, the best interest standard, harm principle, and other standards are often applied when concerns arise over surrogate decision-making. This chapter presents a discussion of the ethical principles and a recommended approach to managing clinical situations with uncertain or conflicting surrogate decision-makers.

Download Full-text

Cross-sectional survey of surrogate decision-making in Japanese medical practice

BMC Medical Ethics ◽

10.1186/s12910-021-00698-0 ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Masashi Tanaka ◽

Seiji Bito ◽

Aya Enzo ◽

Takethoshi Okita ◽

Asai Atsushi

Keyword(s):

Decision Making ◽

Large Scale ◽

Healthcare Professionals ◽

Decision Makers ◽

Decision Making Process ◽

Surrogate Decision Making ◽

Cross Sectional Survey ◽

Cross Sectional ◽

Surrogate Decision Makers ◽

Surrogate Decision

Abstract Background Instances of surrogate decision-making are expected to increase with the rise in hospitalised older adults in Japan. Few large-scale studies have comprehensively examined the entire surrogate decision-making process. This study aimed to gather information to assess the current state of surrogate decision-making in Japan. Methods A cross-sectional survey was conducted using online questionnaires. A total of 1000 surrogate decision-makers responded to the questionnaire. We examined the characteristics of surrogate decision-makers and patients, content of surrogate decision-making meeting regarding life-sustaining treatment between the doctors and surrogate decision-makers, extent of involvement of the various parties in the surrogate decision-making process, judgement grounds for surrogate decision-making, and frequency of involvement in the surrogate decision-making process. Results Of the participants, 70.5% were male and 48.3% were eldest sons. Only 7.6% of the patients had left a written record of their preferences and 48.8% of the surrogates reported no knowledge of the patient having expressed their prior intentions regarding medical care in any form. Respondents indicated that their family meetings with healthcare professionals mostly included the information recommended by guidelines in a surrogate decision-making meeting in Japan. Most participants reported a good understanding of the meeting content. Although many participants based their decisions on multiple grounds, surrogates’ considerations may not adequately reflect respect for patient autonomy in Japan. Specifically, the eldest son considered his own preference more frequently than that of the other surrogate decision-makers. In 26.1% of the cases, either zero or one family meeting with healthcare professionals was held. In these cases, significantly fewer decisions involved the participation of healthcare professionals other than the doctor compared to cases with multiple meetings. Conclusions Surrogate decisions in Japan are most commonly made by eldest sons and may not frequently consider the perspectives of other surrogates. The finding that patient preferences were rarely known suggests a role for increased advance care planning.

Download Full-text

Grounds for surrogate decision-making in Japanese clinical practice: A qualitative survey

10.21203/rs.3.rs-24105/v4 ◽

2021 ◽

Author(s):

Masashi Tanaka ◽

Kayoko Ohnishi ◽

Aya Enzo ◽

Taketoshi Okita ◽

Atsushi Asai

Keyword(s):

Decision Making ◽

Clinical Practice ◽

Decision Makers ◽

Best Interests ◽

Surrogate Decision Making ◽

Inclusion Criteria ◽

Surrogate Decision Makers ◽

Surrogate Decision ◽

Factor Type ◽

Family Preference

Abstract Background In the coming years, surrogate decision-making is expected to become highly prevalent in Japanese clinical practice. Further, there has been a recent increase in activities promoting advance care planning, which potentially affects the manner in which judgements are made by surrogate decision-makers. This study aims to clarify the grounds on which surrogate decision-makers in Japan base their judgements.Methods In this qualitative study, semi-structured interviews were conducted to examine the judgement grounds in surrogate decision-making for critical life-sustaining treatment choices in acute care hospitals.Results A total of 228 participants satisfied the inclusion criteria, and 15 were selected for interviews. We qualitatively analysed the content of 14 interview transcripts, excluding one that did not meet the inclusion criteria. Based on this analysis, we extracted 4 core categories, 17 categories, 35 subcategories, and 55 codes regarding judgement grounds in surrogate decision-making. The four core categories were as follows: patient preference–oriented factor (Type 1), patient interest–oriented factor (Type 2), family preference–oriented factor (Type 3), and balanced patient/family preference–oriented factor (Type 4). The Type 4 core category represented attempts to balance the preferences of the patient with those of the surrogate decision-maker.Conclusions Surrogate decision-makers based their decisions on important aspects related to a patient’s life, and they considered not only the patient’s preferences and best interests but also their own preferences. As the need for surrogate decisions will increase in the future, decision-makers will need to consider judgement grounds from a more diverse perspective. 

Download Full-text

Pathways to and Consequences of Surrogate Decision-Making for Older Adults

Innovation in Aging ◽

10.1093/geroni/igaa057.2466 ◽

2020 ◽

Vol 4 (Supplement_1) ◽

pp. 702-702

Author(s):

Pamela Teaster ◽

Cory Bolkan ◽

Shawn Meyers

Keyword(s):

Older Adults ◽

Decision Making ◽

Elder Abuse ◽

Decision Makers ◽

Surrogate Decision Making ◽

Protective Services ◽

Older Americans ◽

Adult Protective Services ◽

Surrogate Decision Makers ◽

Surrogate Decision

Abstract With a burgeoning aging population, there is a growing need for surrogate decision makers, yet oversight of and guidance for them remains inadequate. People needing surrogate decision makers are an especially vulnerable population because they rely on others for care and/or are unable to advocate for themselves. Their vulnerability leaves them susceptible to elder abuse (e.g., physical, sexual, psychological abuse; active and passive neglect; financial exploitation), which affects approximately five million older Americans each year. Personal, financial, and societal impacts can be devastating and are estimated to cost billions annually. The issue of abuse, neglect and exploitation by surrogates has been highly visible nationally, evidence indicates that some surrogate decision makers perpetrate abuse. One purpose of this symposium is to discuss ways in which surrogates do and do not make decisions for older adults. Ramsey-Klawsnik and Burnett present data at the systemic level to illustrate how self-neglect sequelae can result in placement under surrogate decision-making authority of either well-intended or opportunistic others. Bolkan, Teaster, Ramsey-Klawsnik, and Gerow present findings from a six-state study on surrogate decision maker victims and perpetrators who were substantiated in Adult Protective Services cases. Zhao, Katz, and Teaster show, using a survey of M-Turk participants, how a general population makes and is comfortable with surrogate decisions. Discussant Shawn Meyers will pull together the findings by exploring their translation to judicial best practices for making determinations regarding surrogate decision makers and the effects of their decisions on the surrogate as well as collaterals.

Download Full-text