Healthcare surrogates ease the stress on hospitalized elderly

Tracy Woolrich's picture
Elderly are more likely to have healthcare surrogates to make health decisions.
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A new study indicates that when older people are hospitalized and require critical decisions to be made, that they are more likely to rely on family members and healthcare surrogates to make those decisions. It is important for everyone to have advanced directives that include healthcare surrogates in place. When the elderly are involved it is even more crucial.

My full time job is working as a case manager and discharge planner in an ICU at a local hospital. Time after time I have seen patients turn to their family and surrogates for direction during times of crisis. The stress of being ill, being in a strange environment and even medications makes it difficult for the older population to make decisions involving their healthcare.

Our policy is to allow the patient to make their own decisions if they are competent. It they are not we use a “decision making tree” that allows us to use the documented healthcare surrogate (if there is one), spouse, adult child, parent, sibling or other family member to make decisions. The patient can of course turn to any of these individuals to help them with these decisions at the greatest time of need.

We encourage decisions to be made cohesively if possible with everyone in agreement once there has been full discussion with the medical team.

Considering the expanding and aging population, it only makes sense to encourage and support families and friends that are advocating for the patients. The phrase “It takes a village” sometimes rings true.

In this latest study, researchers discovered that that nearly half of the older patients they followed required assistance making decisions within the first two days of being admitted to the hospital.

Dr. Alexia Torke is a center scientist at the Indiana University Center for Aging Research in Indianapolis. Torke indicated in JAMA Internal Medicine that there was not a wealth of information regarding how often patients relied on others to make healthcare decisions while admitted to the hospital. With that in mind, she and her fellow researchers reviewed data on patients who were over 65. These individuals were admitted to hospitals in the Midwest between November 2008 and December 2011. In order to be included in this study they had to be admitted for a period of greater than 48 hours.

Of the over 1,500 participants, at least 1,000 faced a major medical decision that was discussed with the patient or a healthcare surrogate. Of those cases, 570 patients made their decisions on their own, 264 made decisions with the help of their family or surrogate and another 249 handed those decisions over to their family or surrogate.

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Not surprisingly, decision makers were most often the patients' daughters. This was followed by sons and then spouses. I find this to be fairly in line with what I see at my hospital as well.

Within the first 48hours, the research shows that nearly 60 percent of the healthcare surrogates had to make serious decisions regarding life sustaining treatments. In addition about 50 percent were required to make decisions regarding surgery as well as be involved in discharge planning. In my line of work it is a rare individual that will not ask the opinion of their family or friends as to what rehab center they should go to or what home health care agency they should use.

The research also found that those who required the help of a surrogate were often victims of poor outcomes. They were the ones that ended up in the ICU, on a ventilator, requiring a feeding tube or be sent to a nursing home or hospice at D/C.

It would be easy to assume that leaving your healthcare decisions to others make outcomes worse. In reality however, it is because of the severity of illness that required the use of healthcare decision makers, that the patients fell victim to their illnesses…not their family and friends.
In the study, the researchers also found that only about 25 percent of the patients had advanced directives.

Advanced directives are just what it says. It is the directions that the individual makes in advance to speak for them if they cannot speak for themselves. It usually includes a living will indicating if they would want to be resuscitated, placed on a ventilator, have a feeding tube placed, etc.

Those forms may or may not include however who is to make their decisions if they are unable to. In most cases, those decisions will fall to the family members unless otherwise specified.

Sometimes having a family friend, someone that is trusted but not intimately involved, is a better choice. It is difficult to make critical decisions when exceedingly and emotionally attached to the outcome.

These decisions need to be made in advance with full family involvement and open disclosure. Nothing is worse than having a family member discover that they are not the one to make healthcare decisions, but a neighbor instead.

Take home message:
It is a good idea to have a healthcare surrogate form in place so that there is NO question as to who you want to help make decisions for you. A health care surrogate may be a family member, but does not need to be. He/she however should be someone who:

  • you can trust and understands your wishes;
  • will be able to communicate with your family;
  • is willing to take on this responsibility;
  • is fully aware of your wishes regarding medical treatment and end of life decisions.

Sources:
JAMA

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