April 2008




Surrogate decision-making

by Matt Young EyeWorld Contributing Editor



The elderly may want to make their wishes about elective surgery, such as cataract removal, known before the onset of dementia

A new study, published in the December 2007 issue of the Journal of Cataract & Refractive Surgery, suggests surrogate decision makers often make wrong choices about what patients want. The study, which compared the desire of normal eye patients for cataract surgery with what their surrogates believed they wanted, found large discrepancies. “Current methods of decision making in elective surgery for patients unable to make autonomous decisions may be seriously flawed,” wrote Bhavna P. Sheth, M.D., professor of ophthalmology, Medical College of Wisconsin, Milwaukee, and study co-authors Anand V. Mantravadi, M.D., Russell S. Gonnering, M.D., and Douglas J. Covert, M.D.

For comparison’s sake

Researchers analyzed 37 patients’ views on cataract surgery. They were asked whether they would elect to have cataract surgery in a) their current state of health and b) in the event of moderate dementia. They also chose a family member as a surrogate decision maker, who was then contacted and asked about the patients’ wishes as well. A physician also was asked about the patients’ wishes. “In the current state of health scenario, with a visually significant cataract, most patients desired cataract surgery (94%), while physicians projected all such patients would want surgery,” the study authors wrote. “In a scenario of progressive dementia with a cataract, 50% of the patients desired cataract surgery and 25% of physicians thought the patients would want surgery.”

Physicians often doubted their own ability to make accurate choices for patients given a state of patient dementia. Only 56% felt their choice was accurate. Hence, inconsistencies were beginning to emerge among patient and proxy responses. Even family members—chosen by the patients to represent their wishes—did not accurately do so. Regarding whether patients wanted to remove a visually significant cataract given their current state of health, “the percentage agreement between the patients and their designated surrogate decision maker … was 72%,” the authors wrote. The question related to dementia caused that percentage to drop precipitously. Only 34% agreement existed between patients and surrogate decision makers. “The reduced model ê coefficient and the full model chi-square analysis, there was no more agreement than expected by chance alone,” the study authors wrote. Patients and surrogate decision makers even disagreed over whether they had previously talked about elective surgery decision-making. “When patients and surrogates were asked independently whether elective surgical preferences were discussed should a future situation arise causing inability of autonomous decision making, nearly half the patient–surrogate pairs were in disagreement that such a discussion took place,” the authors wrote.

Overall, family members erred on the side of providing elective intervention, while physicians were more cautious and chose to withhold it. This is also in line with family and physician choices related to resuscitation preferences, the authors noted. Although cataract surgery is marked by excellent success rates and rapid visual recovery—these results demonstrate that inaccuracy “is nonetheless disturbing,” the study authors noted. “The critical ethical importance of accurately approximating incapacitated patients’ true wishes should be held to the highest standards regardless of the proposed medical intervention,” the authors wrote. “The inaccuracy of such an approach in elective surgery, as suggested in this study, along with previous findings in end-of-life scenarios, represents a complex ethical dilemma. Clearly, surrogate decision making is a valuable approach to decision making. However, the inaccuracies of such projections suggest that a renewed emphasis on ‘best interest’ considerations by all parties involved and advanced written plans with specific attention to elective surgical scenarios may enhance this decision-making process.”

“Impossible” to discuss every eventuality

Mark Packer, M.D., clinical associate professor, ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, noted that it’s impossible to discuss every eventuality with someone who might act as a surrogate. “The fact is, you don’t know how you would feel anyway,” Dr. Packer said. “You just have to trust the person you appoint that he is going to do what he thinks is best for you.” Instead, Dr. Packer recommended having a discussion with your surrogate about what your general philosophy is about certain situations. “If I’m in a vegetative state, I probably don’t want to go on living,” Dr. Packer said. That’s something you could convey to your surrogate. Otherwise, getting specific with regards to certain surgeries could be excessive. Since there are varying degrees of dementia, you might even have to address various degrees of dementia for each type of surgery if you go this route. It might be a good idea to at least make sure your medical power of attorney is known. “Any of us could have an accident tomorrow that makes us incompetent to make medical decisions for ourselves,” Dr. Packer said.

Editors’ note: Dr. Packer has no financial interests related to his comments. Drs. Sheth, Mantravadi, Gonnering, and Covert have no financial interests related to this study.

Contact Information

Packer: 541-687-2110, mpacker@finemd.com

Sheth: bsheth@mcw.edu

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