Discussing Patient Values, Goals, and Preferences During Surrogate Decision Making

Clinicians are called to elicit patient values, goals, and preferences, particularly during surrogate decision making, when surrogates (often relatives or friends) make decisions on the patient's behalf. It is currently unknown which clinician questions work best to initiate a discussion with surrogates about the patient's values, goals, and preferences to guide treatment decision making. We audio recorded 27 clinician-surrogate conversations and used conversation analysis to determine how clinicians elicited patient values, goals, and preferences and how surrogates responded in naturally occurring treatment decision-making conversations. No clinician asked directly what the patient valued or what their goals were. Instead, clinicians asked multiple questions to invite the patient's voice into the conversation. When clinicians asked surrogates what the patient said or would say, surrogates responded by implicitly communicating the patient's values. When clinicians asked broad questions about who the patient was or what they enjoyed doing, surrogate responses rarely were values that were used to inform decision-making about a treatment. Conversely, when specific treatment decisions were asked about for what the patient would want or find acceptable, surrogates at times shared narratives and accounts that conveyed patient values. To incorporate the patient's voice into the conversation, it is likely useful for clinicians to ask multiple questions about what the patient has said, what they would say, and what the patient would find acceptable. In addition, connecting stated values to the treatment decision is essential to ensure that patients receive the care that they would choose for themselves.