In this survey of inpatient resident and attending physicians at three urban hospitals, physicians relied upon a variety of ethical considerations when making surrogate decisions for hospitalized adults. Consistent with standard ethical models of decision making, a vast majority of physicians rated factors reflecting patient preferences and best interest as very or extremely important. Nevertheless, when asked to identify the single most important factor, many fewer (one-third) reported they relied primarily on patient preferences to guide decision making. There was no association between reliance on patient preferences and physicians’ beliefs about the ethical principles that should guide surrogate decision making. More surprisingly, there was no association between physicians’ reliance on patient preferences and whether the patient had expressed such preferences through a living will or prior discussion regarding their care, or when the physician had judged this information to be helpful in decision making. When these documents were present and judged to be helpful, physicians still selected patient preferences as most important less than half of the time.
These data do not mean that physicians are unaware of standard ethical guidelines for surrogate decision making. Three in four respondents identified either advance directives or substituted judgment as the standard that physicians should use. The data also do not mean physicians’ routinely disregard patient preferences, nor that in reporting an alternative guiding standard, they don’t take preferences into account. However, they do raise the question of the degree to which there is concordance between ethical standards, on the one hand, and clinical practice, on the other.
There are several possible explanations for any such lack of concordance. First, in many cases information about patient’s preferences was not available due to lack of a living will or prior conversations. Second, available living wills or prior conversations about care may not apply to the clinical situation at hand.12, 13
They may not address the specific clinical decision that must be made or they may have been written prior to major changes in the patient’s health status that could affect decision making. This is supported by our finding that even when living wills or prior conversations had occurred, physicians relied on patient preferences less than half the time.
Third, although physicians are taught that autonomy should be given priority in both patient decision making and surrogate decision making, physicians may perceive that acting in the patient’s best interests is at least equally important. Our prior qualitative work has identified that physicians feel a sense of duty to determine the patient’s best interests and to promote them in clinical care.4
At the bedside, this duty may be seen as equally important as ethical teachings about autonomy. As evidence for this, even when patients had living wills and evidence of prior conversations that were judged to be helpful, physicians selected patient preferences as the most important factor less than half of the time.
Fourth, patients who select “what was best for the patient overall” may have been making a more global assessment that included both best interests and patient preferences. We found that close to a third of those who rated “what was best for the patient overall” also rated patient preferences as highly important. It is possible these physicians regarded the former item as a broader concept that included patient preferences. A few small qualitative studies have found that surrogates most often rely on either patient best interests or on a combination of best interests and patient wishes, but do not clearly distinguish between these two ethical concepts.14, 15
Our prior qualitative work4
suggests that physicians sometimes take a similar clinical approach.
We did find evidence that patient preferences were more likely to be ranked as most important in the ICU setting. In the ICU, decisions with immediate life and death consequences arise on a regular basis and patients are often unable to make decisions. It is possible that when the benefits of aggressive life-sustaining interventions are uncertain, patient preferences are given increased importance.
We also found a decreased reliance on patient preferences with increasing age. This may reflect ageist assumptions that the preferences and values of older adults are less important than those of younger adults. Another possible explanation is that physicians may ascribe to a “natural life span” perspective, which includes the belief that death is an unavoidable event and that health care in advanced age should not focus primarily on extending life.16
Some physicians may hold this view, and would place less weight on the preferences of older adults when considering aggressive medical interventions than they would for a younger person.
In recent years, the reliance on advance directives and substituted judgment has been criticized based on substantial empirical evidence.17
Studies have found that patients want physicians and family members to have some leeway in decision making,18, 19
that patients change their own minds about treatment over time,20-22
and that surrogates23
and physicians24, 25
are poor predictors of patient wishes. These studies were all conducted with patients who were considering a future time when they would be unable to make decisions. By contrast, our study explored the factors that practicing physicians actually used to reach surrogate decisions. We found that physicians rely on a multitude of decision making factors, and that the factor selected as most important may vary from case to case.
This study has several limitations. Understanding the basis for any behavior is a complex task, and our work examining physicians’ self-reported motivations provides an incomplete picture of clinical decision making. Other factors, such as the surrogate’s reasoning, may have been quite different from the physician’s and also may have impacted the final decision. Second, we explored the beliefs and experiences of a limited number of physicians from a single metropolitan area. Third, although we attempted to limit the potential selection of particularly memorable or outlying cases by surveying physicians close to the time of surrogate decision making, physicians may have reported their most memorable or most distressing experience rather than the most recent one. This could have introduced bias. For example, cases may be more distressing if the patient’s own wishes are unknown or are not effectively incorporated into the decision making process. Finally, because our outcome variable, reliance on patient preferences, was common (occurring 29% of the time) the odds ratios in our analysis may be more extreme than the true risk ratios.
In conclusion, although widely accepted models of surrogate decision making rank patient preferences as the most important ethical guideline for surrogate decision making2, 3
and a majority of house staff and attending physicians identify this as the most important guideline, physicians rely on a variety of factors when making decisions in the hospital setting. Even when helpful information about the patient’s preferences is available, physicians appear to incorporate other decision making factors that may be at least equally important. This difference between ethical theory and physician practice could encourage us either to compel physicians to weigh patient preferences more heavily in surrogate decision making or to consider whether the ethical framework for surrogate decisions should be modified to allow for balancing of multiple decision making factors.