Talk it out to ease tough end-of-life decisions

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Too few older adults make end-of-life medical decisions ahead of time—and even when they do identify a loved one to make decisions for them, their wishes may remain unclear.

For a new study published in the Journal of the American Geriatrics Society, researchers interviewed 350 veterans 55 years of age or older, and separately interviewed the individuals the veterans had selected as their surrogates. To gauge the surrogates’ knowledge, they asked whether the patient would prefer treatment even if that treatment would leave the patient severely impaired physically, cognitively, or in severe pain.

Only 20% of surrogates could predict the patient’s wishes for life-sustaining treatment.

Advance care planning that allows older adults to prepare for future treatment decisions will ideally involve a surrogate who can make decisions on their behalf.

Yet more than 40 percent of the veteran-surrogate pairs agreed the veterans had not communicated their wishes with their surrogates, or completed a living will health care proxy.

Further, patients and surrogates were frequently at odds about whether they had talked about end-of-life decisions. Only 20 percent of surrogates could predict the patient’s wishes for life-sustaining treatment. That knowledge was only slightly better among pairs who had agreed they had communicated than those who did not agree.

The data strongly suggest that surrogates must be more involved in advance care planning, researchers say.

“You can’t assume advanced care planning achieves the goal of making sure the surrogate understands what the patient wants,” says Terri Fried, professor of medicine (geriatrics) at Yale University.

“Planning needs to include a facilitated discussion between the patient and the surrogate to make sure they are hearing each other and talking about things that are important to the patient.”

Too much hope can extend end-of-life suffering

To that end, older adults and their surrogates may need extra help with planning. That help may take the form of a clinician facilitator or an internet-based tool. Fried and colleagues are planning to study the effectiveness of using materials tailored to the patient and will assess the impact of conducting motivational interviews.

“The jury is still out on the best way to help people,” Fried says.

The US Department of Veterans Affairs Health Services Research and Development Service, and the Claude D. Pepper Older Americans Independence Center at Yale University School of Medicine supported the work.

Source: Yale University