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The Accuracy of Substituted Judgments in Patients with Terminal Diagnoses

Daniel P. Sulmasy, OFM, MD, PhD; Peter B. Terry, MD, MA; Carol S. Weisman, PhD; Deborah J. Miller, RN, PhD; Rebecca Y. Stallings, MHS; Margaret A. Vettese, RN, PhD; and Karen B. Haller, RN, PhD
[+] Article, Author, and Disclosure Information

From Georgetown University Medical Center, Washington, D.C.; and the Johns Hopkins Medical Institutions, Baltimore, Maryland. Acknowledgments: The authors thank Ruth Faden and Edmund Pellegrino for their advice during the design and analysis of this project and Stephanie Poe and Andrea Kalfoglou for interviewing patients. Grant Support: By the National Institute for Nursing Research (NIH-RO1NR03045-01A1). Dr. Sulmasy is supported by a Soros Faculty Scholar Award of the Project on Death in America. Requests for Reprints: Daniel P. Sulmasy, OFM, MD, PhD, Center for Clinical Bioethics, Room 236, Building D, Georgetown University Medical Center, Washington, DC 20007; e-mail sulmasyd@gunet.georgetown.edu. Current Author Addresses: Dr. Sulmasy: Center for Clinical Bioethics, Room 236, Building D, Georgetown University Medical Center, Washington, DC 20007.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1998;128(8):621-629. doi:10.7326/0003-4819-128-8-199804150-00002
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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% CI, 1.6 to 2.3]), the patient having private insurance (OR, 1.4 [CI, 1.1 to 1.7]), the surrogate's level of education (OR, 1.5 [CI, 1.2 to 1.9]), and the patient's level of education (OR, 1.7 [CI, 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 [CI, 0.5 to 0.7]), surrogate experience with life-sustaining treatment (OR, 0.4 [CI, 0.3 to 0.5]), surrogate participation in religious services (OR, 0.67 [CI, 0.50 to 0.91]), and a diagnosis of heart failure (OR, 0.6 [CI, 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.


judgment ; coma


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Figure 1.
Accuracy of substituted judgments according to diagnosis and scenario.P

Mean Surrogate Accuracy in Matching Patient Preferences Scale scores are given for three hypothetical scenarios. Responses of 50 surrogates of 50 patients with congestive heart failure (CHF), AIDS, amyotrophic lateral sclerosis (ALS), unresectable non-small-cell lung cancer (CA), and chronic obstructive pulmonary disease (COPD) were scored. Scores of 50 general internal medicine (GIM) patients are also shown. Scores did not differ significantly by diagnosis. Overall accuracy was higher for the permanent coma scenario than for the small chance and severe dementia scenarios ( = 0.001 by Friedman two-way analysis of variance).

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Figure 2.
Percentage of patients who would choose each intervention according to scenario and intervention.n

Percentages are the proportion of patients ( = 300) who would choose the following interventions in three hypothetical scenarios intensive care (ICU), ventilator treatment (Vent), cardiopulmonary resuscitation (CPR), feeding tube placement (Feed), surgery to fix a correctable problem (Surg), hemodialysis (Dial), esophagogastroduodenoscopy (EGD), nasotracheal suction (Suct), phlebotomy (Phlb), or chest roentgenography (CXR).

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