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Do Patients Want their Families or their Doctors to Make Treatment Decisions in the Event of Incapacity, and Why?

ABSTRACT: BACKGROUND:Current practice relies on patient-designated and next-of-kin surrogates, in consultation with clinicians, to make treatment decisions for patients who lose the ability to make their own decisions. Yet, there is a paucity of data on whether this approach is consistent with patients' preferences regarding who they want to make treatment decisions for them in the event of decisional incapacity. METHODS:Self-administered survey of patients at a tertiary care center. RESULTS:Overall, 1169 respondents completed the survey (response rate=59.8%). Of the 229 respondents who had previously designated a surrogate, 78.2% wanted their surrogate to make treatment decisions in the event of decisional incapacity, whereas 21.8% wanted their doctors to make treatment decisions. Of the 822 respondents who had not designated a surrogate, 66.1% wanted their family to make treatment decisions, whereas 33.9% wanted their doctors to make treatment decisions. The most common explanation provided for why respondents wanted their surrogate or family to make treatment decisions for them in the event of decisional incapacity was the belief that loved ones knew the patient's treatment preferences. CONCLUSIONS:Contrary to current practice, 33.9% of respondents who had not designated a surrogate, and 21.8% of those who had designated a surrogate indicated that they wanted their doctors to make treatment decisions for them in the event of decisional incapacity. Moreover, many of those who wanted their surrogates or family members to make treatment decisions explained this preference by citing a belief that loved ones knew the patient's treatment preferences. This belief is undermined by prior research which suggests that surrogates and family members frequently are unable to predict which treatments their charges would want. Future research should assess these two concerns with current practice and, where necessary, identify approaches to address them.

SUBMITTER: Wendler D

PROVIDER: S-EPMC5609846 | biostudies-literature | 2016

REPOSITORIES: biostudies-literature

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Do Patients Want their Families or their Doctors to Make Treatment Decisions in the Event of Incapacity, and Why?

Wendler David D Wesley Robert R Pavlick Mark M Rid Annette A

AJOB empirical bioethics 20160426 4

<h4>Background</h4>Current practice relies on patient-designated and next-of-kin surrogates, in consultation with clinicians, to make treatment decisions for patients who lose the ability to make their own decisions. Yet, there is a paucity of data on whether this approach is consistent with patients' preferences regarding who they want to make treatment decisions for them in the event of decisional incapacity.<h4>Methods</h4>Self-administered survey of patients at a tertiary care center.<h4>Res ...[more]

PMID: 28944254

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Project description:BackgroundTo assess the differences across continental regions in terms of stroke imaging obtained for making acute revascularization therapy decisions, and to identify obstacles to participating in randomized trials involving multimodal imaging.MethodsSTroke Imaging Repository (STIR) and Virtual International Stroke Trials Archive (VISTA)-Imaging circulated an online survey through its website, through the websites of national professional societies from multiple countries as well as through email distribution lists from STIR and the above mentioned societies.ResultsWe received responses from 223 centers (2 from Africa, 38 from Asia, 10 from Australia, 101 from Europe, 4 from Middle East, 55 from North America, 13 from South America). In combination, the sites surveyed administered acute revascularization therapy to a total of 25,326 acute stroke patients in 2012. Seventy-three percent of these patients received intravenous (i.v.) tissue plasminogen activator (tPA), and 27%, endovascular therapy. Vascular imaging was routinely obtained in 79% (152/193) of sites for endovascular therapy decisions, and also as part of standard IV tPA treatment decisions at 46% (92/198) of sites. Modality, availability and use of acute vascular and perfusion imaging before revascularization varied substantially between geographical areas. The main obstacles to participate in randomized trials involving multimodal imaging included: mainly insufficient research support and staff (50%, 79/158) and infrequent use of multimodal imaging (27%, 43/158) .ConclusionThere were significant variations among sites and geographical areas in terms of stroke imaging work-up used tomake decisions both for intravenous and endovascular revascularization. Clinical trials using advanced imaging as a selection tool for acute revascularization therapy should address the need for additional resources and technical support, and take into consideration the lack of routine use of such techniques in trial planning.

Project description:A number of recent functional Magnetic Resonance Imaging (fMRI) studies on intertemporal choice behavior have demonstrated that so-called emotion- and reward-related brain areas are preferentially activated by decisions involving immediately available (but smaller) rewards as compared to (larger) delayed rewards. This pattern of activation was not seen, however, when intertemporal choices were made for another (unknown) individual, which speaks to that activation having been triggered by self-relatedness. In the present fMRI study, we investigated the brain correlates of individuals who passively observed intertemporal choices being made either for themselves or for an unknown person. We found higher activation within the ventral striatum, medial prefrontal and orbitofrontal cortex, pregenual anterior cingulate cortex, and posterior cingulate cortex when an immediate reward was possible for the observer herself, which is in line with findings from studies in which individuals actively chose immediately available rewards. Additionally, activation in the dorsal anterior cingulate cortex, posterior cingulate cortex, and precuneus was higher for choices that included immediate options than for choices that offered only delayed options, irrespective of who was to be the beneficiary. These results indicate that (1) the activations found in active intertemporal decision making are also present when the same decisions are merely observed, thus supporting the assumption that a robust brain network is engaged in immediate gratification; and (2) with immediate rewards, certain brain areas are activated irrespective of whether the observer or another person is the beneficiary of a decision, suggesting that immediacy plays a more general role for neural activation. An explorative analysis of participants' brain activation corresponding to chosen rewards, further indicates that activation in the aforementioned brain areas depends on the mere presence, availability, or actual reception of immediate rewards.

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Do Patients Want their Families or their Doctors to Make Treatment Decisions in the Event of Incapacity, and Why?

Publications

Do Patients Want their Families or their Doctors to Make Treatment Decisions in the Event of Incapacity, and Why?

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