title: The Influence of Surrogate Decision Makers on Clinical Decision Making for Critically Ill Adults.
abstract: OBJECTIVE
  Intensive care unit patients rarely have decisional capacity and often surrogates make clinical decisions on their behalf. Little is known about how surrogate characteristics may influence end-of-life decision making for these patients. This study sought to determine how surrogate characteristics impact physicians' approach to end-of-life decision making.
  
  
  METHODS
  From March 2011 to August 2011, a survey was fielded to 1000 randomly sampled critical care physicians using a modified Dillman approach. The survey included a hypothetical vignette to examine how physicians' approach varied based on patient age, patient-surrogate relationship, surrogate-staff relationship, basis for surrogate's stated preferences, and surrogate's understanding of patient's condition. Outcomes included physicians' beliefs regarding (1) appropriateness of cardiopulmonary resuscitation (CPR); (2) appropriate locus of decision making for the patient; (3) degree to which a physician would try to influence a surrogate if disagreement was present; and (4) physician strategies to discussing end-of-life with surrogates.
  
  
  RESULTS
  Of 922 eligible physicians, 608 (66%) participated. Across all vignettes, CPR was felt to be less appropriate and surrogates less likely to be given priority with an older rather than younger patient (15% vs 63% and 50% vs 65%, both P values <.001). Cardiopulmonary resuscitation was considered less appropriate when the surrogate-patient relationship was not close (34% vs 44%, P = .03) and the surrogate's understanding was poor (34% vs 43%, P = .05). No other surrogate characteristics examined yielded statistically significant associations.
  
  
  CONCLUSIONS
  Some surrogate characteristics may modify clinicians' beliefs and practices regarding end-of-life care, suggesting the nuances of the surrogate-physician relationship and clinical decision making for critically ill patients.
authors.affiliation: Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL, USA.
authors.forename: Raj D
authors.initials: RD
authors.lastname: Shah
authors.affiliation: Chicago Consortium for School Research, University of Chicago, Chicago, IL, USA.
authors.forename: Kenneth A
authors.initials: KA
authors.lastname: Rasinski
authors.affiliation: MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL, USA Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA Department of Medicine, Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, MD, USA Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA Department of Pharmacy Practice, University of Illinois at Chicago School of Pharmacy, Chicago, IL, USA galexand@jhsph.edu.
authors.forename: G Caleb
authors.initials: GC
authors.lastname: Alexander
mesh_terms: D000328:Adult; D016887:Cardiopulmonary Resuscitation / Q000941:ethics / Q000523:psychology; D017028:Caregivers / Q000523:psychology*; D000066491:Clinical Decision-Making / Q000941:ethics / Q000379:methods*; D003422:Critical Care / Q000523:psychology*; D003657:Decision Making; D005260:Female; D006801:Humans; D008020:Life Support Care / Q000941:ethics / Q000523:psychology; D008297:Male; D008875:Middle Aged; D010820:Physicians / Q000523:psychology*; D016414:Resuscitation Orders / Q000941:ethics / Q000523:psychology; D011795:Surveys and Questionnaires; D020458:Third-Party Consent
keywords: communication barriers; conflict; intensive care; medical ethics; patient–physician relationship; withholding treatment