It comes as no surprise to anyone with experience caring for patients at the end of life that family members often have difficulty predicting a patient’s desire for life-sustaining treatments. Reasons for this are less well-understood, however.
“Past efforts to identify factors associated with inaccuracy in predicting desire for treatment have been rather disappointing so far,” says Gina Bravo, PhD, a professor of public health at Canada’s University of Sherbrooke.
Researchers hypothesized that the reason family members have difficulty in predicting a loved one’s desire to receive treatments in hypothetical situations is because of discrepant quality of life assessments.1
“My hypothesis was based on intuition, rather than previous studies. To my knowledge, no studies had yet explored this issue,” says Bravo, the study’s lead author. Previous research had inconsistent findings. “One study would find women, for example, to have better predictive abilities than men, another would find men to be more accurate, while a third would conclude that both genders were equally accurate,” says Bravo.
Intuitively, one would expect surrogates who live with the older adult to have better predictive abilities. “Cohabiting provides more occasions to discuss the type of healthcare a person would want, should he or she become decisionally incapacitated,” notes Bravo. “Yet, here again, results are mixed.”
In fact, most studies conclude that cohabiting does not make a person better in predicting whether a close relative would want to receive a given treatment. “This is a somewhat counterintuitive result,” says Bravo.
New Interventions Needed
Bravo believed that inaccuracy in predicting desire for treatment could be due to inaccuracy in judging quality of life. The researchers asked 235 community-dwelling adults aged 70 and over to rate their quality of life and desire for specified interventions in their current state, mild to moderate stroke, incurable brain cancer, and severe dementia.
A surrogate chosen by the older adult was asked to predict the older adult’s responses. The more the surrogate overestimated quality of life compared to the older adult, the more he or she overestimated the older adult’s desire to be treated.
The finding underscores the importance of discussing anticipated quality of life in states of cognitive decline, the researchers wrote.
Bravo sees the fact that surrogates typically rate quality of life more poorly than their close relatives as an important ethical consideration. “This phenomenon has been observed in many different populations,” she says.
Having rated quality of life poorly, the surrogate would then be inclined to refuse an intervention proposed to their relative — perhaps unknowingly going against their relative’s wish. “This could have serious consequences for the relative, especially if the proposed intervention was life-prolonging,” says Bravo.
The study’s findings suggest that greater understanding on the part of the surrogates could help them make decisions more in line with those that their relatives would have made for themselves. “What we found, however, is an association — not a causal relationship,” notes Bravo. “Hence, the next step would be to formally test, ideally in a randomized trial, new interventions to determine whether they help surrogates to make more consistent decisions.”
Bravo says future developments in this area are not easy to predict. “There is a need, though, to design new interventions aimed at helping potential surrogates better understand how their older relatives view life under hypothetical states of severe cognitive impairment,” she says.
REFERENCE
1. Bravo G, Sene M, Arcand M. Surrogate inaccuracy in predicting older adults’ desire for life-sustaining interventions in the event of decisional incapacity: is it due in part to erroneous quality-of-life assessments? Int Psychogeriatr 2017:1-8. doi: 10.1017/S1041610217000254. [Epub ahead of print].
SOURCE
• Gina Bravo, PhD, Professor of Public Health, University of Sherbrooke, Canada. Email: [email protected].
It comes as no surprise to anyone with experience caring for patients at the end of life that family members often have difficulty predicting a patient’s desire for life-sustaining treatments. Reasons for this are less well-understood, however.
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