The Accuracy of Surrogate Decision Making in Elective Surgery

1
The Accuracy of Surrogate Decision Making in
Elective Surgery

• Anand Mantravadi MD, Bhavna Sheth MD, Russell
  Gonnering MD, FACS, Douglas J. Covert MD, MPH
• The Eye Institute - Medical College of Wisconsin
  Milwaukee, Wisconsin

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Purpose

• For competent patients autonomous medical
  decision-making is the ethical standard.
• There are a growing number of patients who cannot
  makeautonomous health care decisions and
  accurate decisionmaking for this population is a
  concern.
• Surrogate decision-making attempts to preserve
  patientautonomy in such situations.
• Doubt regarding the accuracy of proxy predictions
  has been raised in end of life scenarios.
• This investigation is designed to assess the
  accuracy ofsurrogate decision making for
  elective cataract surgery.

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Methods

• Decisions regarding elective cataract surgery of
  currently competent, elderly patients were
  compared with the predictions of patient
  identified surrogate decision makers in scenarios
  of current state of mental health, and
  progressive dementia
• Thirty-seven patients were identified (age gt50,
  Mini-Mental Status Score gt20, absence of
  significant non-cataract pathology) consecutively
  at a scheduled clinic visit to a single provider.
• Patient preferences for cataract surgery in
  current state of health and hypothetical
  progressive dementia were assessed on a Likert
  scale.
• Patient-identified surrogate decision makers were
  contacted within 48 hours and were asked to
  predict the patients preferences for surgery
  under circumstances of the patients current
  state of health, and moderate dementia
• Independently, a survey of community
  ophthalmologists was solicited.
• Concordance of surrogate predictions with patient
  preferences (n32 pairs) was assessed.

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Results
Current state of health scenario Designated
proxys understanding of patients elective
surgery preference (n 32)
Percent agreement 71.9 Kappa coefficient
0.652 (plt.0001) Chi Square 16.5 (p0.002)
More agreement than is expected by chance alone
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Results
Progressive Dementia Scenario Designated proxys
understanding of patients elective surgery
preference (n 32)
Percent agreement 34.4 Kappa coefficient
0.228 Chi Square 14.4 (p0.57)
No more agreement than is expected by chance alone
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Results
Discussion of elective surgery situations between
Patient and Designated Proxy
Percent agreement 17/32 53.1 Percent
disagreement (discordance) 15/32 46.9 Chi
square 0.43 (p.84)
There is no more agreement than is expected by
chance alone
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Discussion

• The disturbing implications of the inaccuracy of
  surrogate decision making for end of life
  scenarios and resuscitation preferences4,8-9,11-14
  are self-evident.
• The decision to proceed with elective cataract
  surgery by patients, proxies, and physicians in
  scenarios of moderate dementia may bear less
  gravity - likely supported by the widely held
  public perceptions of rapid visual rehabilitation
  and success rates.
• However, the critical ethical importance of
  accurately approximating incapacitated patients
  true wishes should be held to the highest
  standards regardless of the proposed medical
  intervention.
• The fundamental basis for surrogate
  decision-making is the well-intentioned
  propagation of patient autonomy in situations of
  mental incapacity15.
• The inaccuracy of such an approach in elective
  surgery as demonstrated in this study, along with
  prior findings in end of life scenarios,
  represents a complex ethical dilemma.

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Conclusion

• These findings suggest the current methods of
  decision-making in elective surgery for patients
  unable to make autonomous decisions may be
  seriously flawed.
• This extends previous findings of inaccuracy with
  the substituted judgment approach in end of life
  issues to reflect elective surgical scenarios.

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