The accuracy of substituted judgments in patients with terminal diagnoses

Daniel P. Sulmasy, Peter Browne Terry, Carol S. Weisman, Deborah J. Miller, Rebecca Y. Stallings, Margaret A. Vettese, Karen B. Haller

Research output: Contribution to journalArticle

Abstract

Background: Patients' loved ones often make end-of-life treatment decisions, but the accuracy of their substituted judgments and the factors associated with accuracy are poorly understood. Objective: To assess the accuracy of judgments made by surrogate decision makers; ascertain the beliefs, practices, and clinical and sociodemographic factors associated with accuracy of surrogates' decisions; assess the preferences of patients for life-sustaining treatments; and compare differences in accuracy across diagnoses. Design: Cross-sectional paired interviews. Setting: Outpatient practices of three university hospitals. Patients: 250 patients with terminal diagnoses of congestive heart failure, AIDS, amyotrophic lateral sclerosis, lung cancer, and chronic obstructive pulmonary disease (50 patient-surrogate pairs in each group) and 50 general medical patients and their surrogates. Measurements: The accuracy of surrogate predictions was measured by using scales based on 10 potential treatments in each of three hypothetical clinical scenarios. Results: Preferences varied according to mode of treatment and scenario. On average, surrogates made correct predictions in 66% of instances. Accuracy was better for the permanent coma scenario than for the scenarios of severe dementia or coma with a small chance of recovery (P <0.001). In a binary logit model, the accuracy of substituted judgments was positively associated with the patient having spoken with the surrogate about end-of-life issues (odds ratio [OR], 1.9 [95% Cl, 1.6 to 2.3]), the patient having private insurance (OR, 1.4 [Cl, 1.1 to 1.7]), the surrogate's level of education (OR, 1.5 [Cl, 1.2 to 1.9]), and the patient's level of education (OR, 1.7 [Cl, 1.4 to 2.2]). Accuracy was negatively associated with the patient's belief that he or she would live longer than 10 years (OR, 0.6 [Cl, 0.5 to 0.7]), surrogate experience with life-sustaining treatment (OR, 0.4 [Cl, 0.3 to 0.5]), surrogate participation in religious services (OR, 0.67 [Cl, 0.50 to 0.91]), and a diagnosis of heart failure (OR, 0.6 [Cl, 0.5 to 0.8]). Age, ethnicity, marital status, religion, and advance directives were not associated with accuracy. Conclusions: The accuracy of substituted judgments is associated with multiple clinically apparent patient and surrogate factors. This information can help clinicians identify conditions under which substituted judgments are likely to be accurate or inaccurate and can help target populations for education designed to improve the accuracy of surrogate decision making.

Original languageEnglish (US)
Pages (from-to)621-629
Number of pages9
JournalAnnals of Internal Medicine
Volume128
Issue number8
StatePublished - Apr 15 1998

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Odds Ratio
Coma
Heart Failure
Advance Directives
Therapeutics
Education
Patient Preference
Health Services Needs and Demand
Life Change Events
Amyotrophic Lateral Sclerosis
Marital Status
Religion
Patient Education
Insurance
Chronic Obstructive Pulmonary Disease
Dementia
Lung Neoplasms
Decision Making
Acquired Immunodeficiency Syndrome
Outpatients

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Sulmasy, D. P., Terry, P. B., Weisman, C. S., Miller, D. J., Stallings, R. Y., Vettese, M. A., & Haller, K. B. (1998). The accuracy of substituted judgments in patients with terminal diagnoses. Annals of Internal Medicine, 128(8), 621-629.

The accuracy of substituted judgments in patients with terminal diagnoses. / Sulmasy, Daniel P.; Terry, Peter Browne; Weisman, Carol S.; Miller, Deborah J.; Stallings, Rebecca Y.; Vettese, Margaret A.; Haller, Karen B.

In: Annals of Internal Medicine, Vol. 128, No. 8, 15.04.1998, p. 621-629.

Research output: Contribution to journalArticle

Sulmasy, DP, Terry, PB, Weisman, CS, Miller, DJ, Stallings, RY, Vettese, MA & Haller, KB 1998, 'The accuracy of substituted judgments in patients with terminal diagnoses', Annals of Internal Medicine, vol. 128, no. 8, pp. 621-629.
Sulmasy DP, Terry PB, Weisman CS, Miller DJ, Stallings RY, Vettese MA et al. The accuracy of substituted judgments in patients with terminal diagnoses. Annals of Internal Medicine. 1998 Apr 15;128(8):621-629.
Sulmasy, Daniel P. ; Terry, Peter Browne ; Weisman, Carol S. ; Miller, Deborah J. ; Stallings, Rebecca Y. ; Vettese, Margaret A. ; Haller, Karen B. / The accuracy of substituted judgments in patients with terminal diagnoses. In: Annals of Internal Medicine. 1998 ; Vol. 128, No. 8. pp. 621-629.
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abstract = "Background: Patients' loved ones often make end-of-life treatment decisions, but the accuracy of their substituted judgments and the factors associated with accuracy are poorly understood. Objective: To assess the accuracy of judgments made by surrogate decision makers; ascertain the beliefs, practices, and clinical and sociodemographic factors associated with accuracy of surrogates' decisions; assess the preferences of patients for life-sustaining treatments; and compare differences in accuracy across diagnoses. Design: Cross-sectional paired interviews. Setting: Outpatient practices of three university hospitals. Patients: 250 patients with terminal diagnoses of congestive heart failure, AIDS, amyotrophic lateral sclerosis, lung cancer, and chronic obstructive pulmonary disease (50 patient-surrogate pairs in each group) and 50 general medical patients and their surrogates. Measurements: The accuracy of surrogate predictions was measured by using scales based on 10 potential treatments in each of three hypothetical clinical scenarios. Results: Preferences varied according to mode of treatment and scenario. On average, surrogates made correct predictions in 66{\%} of instances. Accuracy was better for the permanent coma scenario than for the scenarios of severe dementia or coma with a small chance of recovery (P <0.001). In a binary logit model, the accuracy of substituted judgments was positively associated with the patient having spoken with the surrogate about end-of-life issues (odds ratio [OR], 1.9 [95{\%} Cl, 1.6 to 2.3]), the patient having private insurance (OR, 1.4 [Cl, 1.1 to 1.7]), the surrogate's level of education (OR, 1.5 [Cl, 1.2 to 1.9]), and the patient's level of education (OR, 1.7 [Cl, 1.4 to 2.2]). Accuracy was negatively associated with the patient's belief that he or she would live longer than 10 years (OR, 0.6 [Cl, 0.5 to 0.7]), surrogate experience with life-sustaining treatment (OR, 0.4 [Cl, 0.3 to 0.5]), surrogate participation in religious services (OR, 0.67 [Cl, 0.50 to 0.91]), and a diagnosis of heart failure (OR, 0.6 [Cl, 0.5 to 0.8]). Age, ethnicity, marital status, religion, and advance directives were not associated with accuracy. Conclusions: The accuracy of substituted judgments is associated with multiple clinically apparent patient and surrogate factors. This information can help clinicians identify conditions under which substituted judgments are likely to be accurate or inaccurate and can help target populations for education designed to improve the accuracy of surrogate decision making.",
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AU - Sulmasy, Daniel P.

AU - Terry, Peter Browne

AU - Weisman, Carol S.

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AU - Stallings, Rebecca Y.

AU - Vettese, Margaret A.

AU - Haller, Karen B.

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N2 - Background: Patients' loved ones often make end-of-life treatment decisions, but the accuracy of their substituted judgments and the factors associated with accuracy are poorly understood. Objective: To assess the accuracy of judgments made by surrogate decision makers; ascertain the beliefs, practices, and clinical and sociodemographic factors associated with accuracy of surrogates' decisions; assess the preferences of patients for life-sustaining treatments; and compare differences in accuracy across diagnoses. Design: Cross-sectional paired interviews. Setting: Outpatient practices of three university hospitals. Patients: 250 patients with terminal diagnoses of congestive heart failure, AIDS, amyotrophic lateral sclerosis, lung cancer, and chronic obstructive pulmonary disease (50 patient-surrogate pairs in each group) and 50 general medical patients and their surrogates. Measurements: The accuracy of surrogate predictions was measured by using scales based on 10 potential treatments in each of three hypothetical clinical scenarios. Results: Preferences varied according to mode of treatment and scenario. On average, surrogates made correct predictions in 66% of instances. Accuracy was better for the permanent coma scenario than for the scenarios of severe dementia or coma with a small chance of recovery (P <0.001). In a binary logit model, the accuracy of substituted judgments was positively associated with the patient having spoken with the surrogate about end-of-life issues (odds ratio [OR], 1.9 [95% Cl, 1.6 to 2.3]), the patient having private insurance (OR, 1.4 [Cl, 1.1 to 1.7]), the surrogate's level of education (OR, 1.5 [Cl, 1.2 to 1.9]), and the patient's level of education (OR, 1.7 [Cl, 1.4 to 2.2]). Accuracy was negatively associated with the patient's belief that he or she would live longer than 10 years (OR, 0.6 [Cl, 0.5 to 0.7]), surrogate experience with life-sustaining treatment (OR, 0.4 [Cl, 0.3 to 0.5]), surrogate participation in religious services (OR, 0.67 [Cl, 0.50 to 0.91]), and a diagnosis of heart failure (OR, 0.6 [Cl, 0.5 to 0.8]). Age, ethnicity, marital status, religion, and advance directives were not associated with accuracy. Conclusions: The accuracy of substituted judgments is associated with multiple clinically apparent patient and surrogate factors. This information can help clinicians identify conditions under which substituted judgments are likely to be accurate or inaccurate and can help target populations for education designed to improve the accuracy of surrogate decision making.

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