 When and How Surrogates Should Be Used for Decision Making

A 68-year-old man with alcoholism is admitted to the hospital with hematemesis and
encephalopathy. The patient’s clinician recommends esophagogastroduodenoscopy. However, the
patient lacks decision-making capacity and has no AD.

When a patient loses decision-making ability, the clinician must rely on a proxy to make the patient's
decisions. If the patient has an AD that identifies a proxy, this decision should be honored (American
College of Physicians, 1998). However, many patients who lack decision-making ability do not have
Alzheimer's disease. In all cases, physicians must find a suitable surrogate.

The perfect surrogate is one who is most familiar with the patient's health-care principles and
priorities (Hayley et al., 1996). Surrogates are normally family members; however, certain states
have a surrogate hierarchy (e.g., court-appointed guardian, spouse, next of kin). In certain cases, the
patient's family and other interested parties might agree that a close friend would be the best
surrogate. (American College of Physicians, 1998) In this situation, the clinician can identify the best
proxy decision maker for the patient (while also trying to reverse the patient's encephalopathy and
recover his decision-making capacity).

Surrogate decision makers should make decisions based on the patient's previously stated beliefs
and goals (i.e., "substituted judgment") (Hayley et al, 1996). Several research, however, have shown
that surrogates are often ignorant of and cannot reliably forecast patient health care values and
goals (Morris BA, 1995).  Furthermore, other researchers have shown that surrogate review of
Alzheimer's disease in elderly patients does not always enhance surrogate-substituted judgement
(Ditto PH, 2001). According to these findings, many surrogates do not consider patients' health care
values and aspirations and focus their choices around what they believe is better for patients (i.e.,
"best interest") (Hayley et al., 1996).

 Use of Cardiopulmonary Resuscitation and Do-Not-Resuscitate Orders

An 82-year-old man is admitted for chest pain due to myocardial infarction. His clinician asks the
patient if he desires CPR should he experience a cardiopulmonary arrest. The patient tells the
clinician that he wants “everything done.”

In practice, physicians cannot conduct CPR unless there is a do-not-resuscitate order (to which the
patient or proxy has consented). Slow codes (i.e., insufficient CPR efforts) are religiously repugnant
(American College of Physicians, 1998). CPR, on the other hand, is a low-yield technique. A meta-
analysis of 48 studies on CPR in the hospital setting discovered that only 41% of patients who
received CPR survived instantly, and only 13% survived to discharge. Notably, age was not a
predictor of post-CPR survival.

CPR performed outside of the hospital is less successful than CPR performed within the hospital in
the elderly. In one report, 492 of 244 people (0.8 percent) who received CPR outside of the hospital
lived to discharge, compared to 17 of 259 (6.6 percent) who received CPR in the hospital. Similarly,
only 0% to 5% of nursing home patients who received CPR outside of the hospital lived to be
discharged (Sweig SC, 1997).

Do-not-resuscitate orders rise with age, even though disease severity is taken into account
(Boyd, et., 1996). However, most of older people do not have a clear idea of what CPR entails, and
the others have not discussed CPR with their physicians (Shmerlin et al., 1988). Furthermore,
patients exaggerate the effectiveness of CPR. However, after learning about the real effectiveness of
CPR, However, after being informed of the actual efficacy of CPR, many elderly persons decline the
procedure (Murphy et al., 1994).

Furthermore, studies have shown that surrogates and clinicians often mispredict elderly people's
preferences for CPR (Uhlmann et al, 1988). Furthermore, doctors cannot conclude an elderly
patient's need for CPR based on whether the patient has Alzheimer's disease (Walker et al., 1995).
These findings highlight the importance of physicians specifically discussing CPR and its effectiveness
for their elderly patients. In the case example, the patient's clinician should address the essence of
CPR (i.e., what is done), its complications and benefits, and the anticipated results with the patient.
In contrast, the patient's decision to refuse CPR should be respected.