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Substituted Judgment: How Accurate Are Proxy Predictions?

Allison B. Seckler, BA; Diane E. Meier, MD; Michael Mulvihill, DrPH; and Barbara E. Cammer Paris, MD
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Grant Support: By grant T35 DK07420-10 from the National Institute for Diabetes, Digestive and Kidney Diseases, by grant K08AG00358 from the National Institute on Aging, and by a Geriatric Academic Development Award from the John A. Hartford Foundation, New York City.

Requests for Reprints: Diane Meier, MD, Box 1070, Mount Sinai Medical Center, One Gustave L. Levy Place, New York, NY 10029.

Current Author Addresses: Ms. Seckler and Drs. Meier and Paris: Box 1070, Mount Sinai Medical Center, One Gustave L. Levy Place, New York, NY 10029.

Dr. Mulvihill: Jewish Home and Hospital for Aged, 120 West 106th Street, New York, NY 10025.


©1991 American College of PhysiciansAmerican College of Physicians


Ann Intern Med. 1991;115(2):92-98. doi:10.7326/0003-4819-115-2-92
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▪ Substituted judgment has been proposed as a method of promoting the autonomy of the mentally incapacitated patient, but little is known about the accuracy of surrogate decision makers in reflecting the true wishes of patients. In this study, surrogate decision makers' views (those of primary care providers and close family members) were compared with the decisions of currently competent chronically ill elderly patients, using a hypothetic cardiopulmonary resuscitation scenario under circumstances of current health and progressive dementia. Concordance between patients and their surrogates was evaluated by assessing percent agreement, kappa coefficient (for concordance beyond chance), and directionality of discrepant responses. Most patient respondents chose to be resuscitated in both scenarios. Although patients predicted that both their physicians (90%) and family members (87%) would accurately represent their wishes, neither family members nor physicians, in fact, were able to adequately predict patients' wishes in both scenarios (kappa ≤ 0.3 in all scenarios; percent agreement range, 59% to 88%). Few patients had ever discussed their resuscitation preferences with either their family member (16%) or their physician (7%). These results cast doubt on the usefulness of a strict substituted judgment standard as an approach to medical decision making for patients with diminished mental capacity.

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