This study suggests that family members of critically ill patients who have no prior experience as a surrogate and who have not had prior conversations with the patient about treatment preferences are more likely to struggle in the role of surrogate. Better clinician–family communication was associated with higher role confidence among surrogates. Higher QOC was also associated with less time on life support for dying patients.
Our findings of factors that predict lower confidence among family members acting as surrogates provide quantitative confirmation of themes identified in several small qualitative studies of surrogate decision making (4
). Vig interviewed families of incapacitated patients and found that surrogates considered several factors helpful in easing the burden of surrogate decision making, including prior conversations with the patient, written advance directives, and shared experiences with loved ones (30
). Kirchhoff et al found that a key element of family members’ comfort with acting as a surrogate was their understanding of the patient’s preferences for future medical care (31
). Our findings extend those of prior studies by employing quantitative strategies in a diverse cohort and by using multivariate methods to control for potential confounding. A clinical implication of our findings is that it may be possible to “risk stratify” family members regarding the likelihood that the role of surrogate will be difficult for them. Our data suggest two questions that may help in this process: Does the family member have prior experience as a surrogate, and has the surrogate had prior conversations with the patient about treatment preferences?
We also found an association between the quality of clinician–family communication and surrogates’ confidence in their role. This finding is important because it suggests that family members’ confidence to act as a surrogate may be modifiable by clinicians, rather than being simply a result of unmodifiable personality traits and life experiences. This has implications for the design of interventions to improve the quality of surrogate decision making in ICUs. It may also shed light on the mechanism of benefit of prior communication interventions, which decreased long-term posttraumatic stress disorder symptoms among surrogates in ICUs (14
We found that higher-quality clinician–family communication was associated with a significantly shorter duration of life support among patients who died. We are not aware of other studies that directly address this question, though it is likely that interventions testing early palliative care consultation (33
), ethics consultation (34
), or proactive family meetings (32
) may achieve their effect through improved QOC. This is in contrast to prior studies reporting that increasing the frequency of communication has no impact on the timing of decisions about life support (15
). We speculate that our focus on the QOC rather than the quantity of communication may explain the difference. High-quality communication may address both cognitive and emotional barriers to decisions to forego life support. For example, high-quality communication may provide surrogates not only the information they need to make patient-centered decisions, but also the support needed to face the emotional impact of EOL decisions. Failure to address these emotional and psychological barriers may make it difficult for surrogates to authorize a transition to comfort-focused EOL care, even when doing so is clearly consistent with the patient’s values.
A strength of the study is that, rather than eliciting surrogates’ global impression of communication quality, we used a validated measure that focuses on surrogates’ assessments of how well specific communication competencies were performed. This allows clinicians interested in improving their communication skills to focus on the specific competencies measured, such as discussing prognosis, active listening, eliciting the patient’s values, providing emotional support, and deliberating with surrogates about treatment decisions.
There are several limitations to our study. Although there were no differences in demographics between enrolled and nonenrolled patients, we cannot exclude the possibility that unmeasured differences existed between these groups, posing a threat to generalizability. The study sample was relatively well educated, and to the extent that less-educated individuals tend to struggle more with medical decisions, our findings may underestimate the true prevalence of problems with surrogate decision making. The study was conducted in one region of the United States and therefore may not be generalizable to areas in which there are different cultural perspectives on surrogate decision making. Another limitation is that we did not ascertain whether surrogates were appointed by the patient or were acting by default “closeness of relationship.” As with all observational studies, this study does not establish a causal relationship between the QOC and timing of decisions to forego life support. We did not measure long-term psychiatric outcomes among surrogates, and therefore could not assess whether higher-quality clinician–family communication was associated with better psychiatric outcomes. Finally, we measured surrogates’ perceptions of how well clinicians performed discrete communication competencies rather than direct observation of the actual communication. Although several studies have documented the construct validity of the QOC instrument, further work is needed to better define the domains of high-quality communication.
In conclusion, we identified two characteristics of family members of critically ill patients who may struggle with surrogate decision making: having no prior experience as a surrogate, and not having engaged in prior conversations with the patient about healthcare preferences. Higher-quality physician–family communication was associated with both higher role confidence among family members to act as surrogates and a shorter duration of use of life support among patients who ultimately die. In aggregate, these findings suggest that a potential strategy to improve surrogate decision making is to develop communication interventions that are tailored to families’ prior experiences as surrogate decision makers and to the level of understanding of the patient’s preferences.