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Pulmonary Embolism I: Introduction
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Substituted judgment: how accurate are proxy predictions?

A B Seckler1, D E Meier, M Mulvihill

  • 1Mount Sinai School of Medicine, New York, New York.

Annals of Internal Medicine
|July 15, 1991
PubMed
Summary
This summary is machine-generated.

Surrogate decision-makers, including family and physicians, inaccurately predict patient wishes for medical interventions like cardiopulmonary resuscitation. Discussing preferences is crucial for respecting patient autonomy in advance care planning.

Keywords:
Death and EuthanasiaEmpirical ApproachProfessional Patient Relationship

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Area of Science:

  • Medical Ethics
  • Geriatric Medicine
  • Decision Science

Background:

  • Substituted judgment aims to uphold patient autonomy for those with diminished capacity.
  • Limited data exists on the accuracy of surrogate decision-makers in reflecting patient wishes.

Purpose of the Study:

  • To compare the accuracy of surrogate decision-makers (physicians, family) with patient preferences.
  • To evaluate the effectiveness of substituted judgment in medical decision-making for incapacitated patients.

Main Methods:

  • Compared decisions of currently competent elderly patients with their surrogate decision-makers.
  • Utilized a hypothetical cardiopulmonary resuscitation scenario under varying health conditions (current and progressive dementia).
  • Assessed concordance using percent agreement, kappa coefficient, and response directionality.

Main Results:

  • Most patients opted for resuscitation in both scenarios.
  • Patients overestimated their surrogates' ability to predict their wishes (physicians: 90%, family: 87%).
  • Surrogates demonstrated poor predictive accuracy (kappa ≤ 0.3, agreement 59%-88%), with low rates of prior preference discussion (family: 16%, physician: 7%).

Conclusions:

  • Strict substituted judgment may be unreliable for medical decision-making in patients with diminished capacity.
  • Enhanced communication regarding patient preferences is essential for accurate advance care planning.
  • Findings highlight a significant gap between perceived and actual surrogate accuracy in reflecting patient autonomy.