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Study examines substituted judgment
Decisions hard when advance directive not present
Making the decision to move from curative to palliative care, or to remain in the hospital or move to a hospice setting, is not easy, but it is especially difficult for physicians who treat seriously ill patients who lack the capacity to make their own health care decisions.
While the first step in this situation is to refer to an advance directive, not all patients have an advance directive. When no directive exists, physicians must use substituted judgment to determine what the patient would want. In a study conducted by physicians and ethicists, the researchers look at the process of substituted judgment that focuses on the patient's autonomy to arrive at a decision.1
The authors point out that over time, a person's choices regarding life-sustaining treatment change, so it is not possible to base a decision on a statement made at some time in the patient's life about their belief in ongoing treatment. Research shows that some people will change their minds over a two-year period. Individuals who complete an advance directive do not change their minds over time, they say.
Other research highlights include:
Findings highlighted the inaccuracy of substituted judgment for patients without living wills, the moderate concordance between patients and doctor or surrogates in decision making, and questions as to whether patients want past wishes to be the basis for decision making.
One alternative model to substituted judgment builds upon community standards in deciding the best interest of patients.
Another alternative model focuses on a narrative approach to decision making by surrogates in which listening to and acting on a patient's account of their life, wishes, and role in their family and community establishes an understanding of the individual and how he or she would decide.
1. Torke AM, Alexander GC, Lantos J. Substituted judgment. The limitations of autonomy in surrogate decision making. J Gen Intern Med 2008; 23:1,514-1,517.