How Surrogates Decide: A Secondary Data Analysis of Decision-Making Principles Used by the Surrogates of Hospitalized Older Adults

Rohit Devnani, James E. Slaven, Gabriel T. Bosslet, Kianna Montz, Lev Inger, Emily S. Burke, Alexia M. Torke

Research output: Contribution to journalArticle

8 Scopus citations


Background: Many hospitalized adults do not have the capacity to make their own health care decisions and thus require a surrogate decision-maker. While the ethical standard suggests that decisions should focus on a patient’s preferences, our study explores the principles that surrogates consider most important when making decisions for older hospitalized patients. Objectives: We sought to determine how frequently surrogate decision-makers prioritized patient preferences in decision-making and what factors may predict their doing so. Design and Participants: We performed a secondary data analysis of a study conducted at three local hospitals that surveyed surrogate decision-makers for hospitalized patients 65 years of age and older. Main Measures: Surrogates rated the importance of 16 decision-making principles and selected the one that was most important. We divided the surrogates into two groups: those who prioritized patient preferences and those who prioritized patient well-being. We analyzed the two groups for differences in knowledge of patient preferences, presence of advance directives, and psychological outcomes. Key Results: A total of 362 surrogates rated an average of six principles as being extremely important in decision-making; 77.8% of surrogates selected a patient well-being principle as the most important, whereas only 21.1% selected a patient preferences principle. Advance directives were more common to the patient preferences group than the patient well-being group (61.3% vs. 44.9%; 95% CI: 1.01–3.18; p = 0.04), whereas having conversations with the patient about their health care preferences was not a significant predictor of surrogate group identity (81.3% vs. 67.4%; 95% CI: 0.39–1.14; p = 0.14). We found no differences between the two groups regarding surrogate anxiety, depression, or decisional conflict. Conclusions: While surrogates considered many factors, they focused more often on patient well-being than on patient preferences, in contravention of our current ethical framework. Surrogates more commonly prioritized patient preferences if they had advance directives available to them.

Original languageEnglish (US)
Pages (from-to)1285-1293
Number of pages9
JournalJournal of general internal medicine
Issue number12
StatePublished - Dec 1 2017


  • aging
  • doctor–patient relationships
  • ethics
  • medical decision-making
  • patient preferences

ASJC Scopus subject areas

  • Internal Medicine

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