Indiana University Center for Aging Research, Indianapolis2Regenstrief Institute, Inc, Indianapolis, Indiana3Division of General Internal Medicine and Geriatrics, Indiana University, Indianapolis4Fairbanks Center for Medical Ethics, Indiana University Hea.
Indiana University Center for Aging Research, Indianapolis2Regenstrief Institute, Inc, Indianapolis, Indiana3Division of General Internal Medicine and Geriatrics, Indiana University, Indianapolis.
JAMA Intern Med. 2014 Mar;174(3):370-7. doi: 10.1001/jamainternmed.2013.13315.
Hospitalized older adults often lack decisional capacity, but outside of the intensive care unit and end-of-life care settings, little is known about the frequency of decision making by family members or other surrogates or its implications for hospital care.
To describe the scope of surrogate decision making, the hospital course, and outcomes for older adults.
DESIGN, SETTING, AND PARTICIPANTS: Prospective, observational study conducted in medicine and medical intensive care unit services of 2 hospitals in 1 Midwestern city in 1083 hospitalized older adults identified by their physicians as requiring major medical decisions.
Clinical characteristics, hospital outcomes, nature of major medical decisions, and surrogate involvement.
According to physician reports, at 48 hours of hospitalization, 47.4% (95% CI, 44.4%-50.4%) of older adults required at least some surrogate involvement, including 23.0% (20.6%-25.6%) with all decisions made by a surrogate. Among patients who required a surrogate for at least 1 decision within 48 hours, 57.2% required decisions about life-sustaining care (mostly addressing code status), 48.6% about procedures and operations, and 46.9% about discharge planning. Patients who needed a surrogate experienced a more complex hospital course with greater use of ventilators (2.5% of patients who made decisions and 13.2% of patients who required any surrogate decisions; P < .001), artificial nutrition (1.7% of patients and 14.4% of surrogates; P < .001), and length of stay (median, 6 days for patients and 7 days for surrogates; P < .001). They were more likely to be discharged to an extended-care facility (21.2% with patient decisions and 40.9% with surrogate decisions; P < .001) and had higher hospital mortality (0.0% patients and 5.9% surrogates; P < .001). Most surrogates were daughters (58.9%), sons (25.0%), or spouses (20.6%). Overall, only 7.4% had a living will and 25.0% had a health care representative document in the medical record.
Surrogate decision making occurs for nearly half of hospitalized older adults and includes both complete decision making by the surrogate and joint decision making by the patient and surrogate. Surrogates commonly face a broad range of decisions in the intensive care unit and the hospital ward setting. Hospital functions should be redesigned to account for the large and growing role of surrogates, supporting them as they make health care decisions.
住院的老年人往往缺乏决策能力，但在重症监护病房和临终关怀环境之外，对于家属或其他代理人做出决策的频率及其对医院护理的影响知之甚少。
描述老年人的代理人决策范围、医院病程和结果。
设计、地点和参与者：前瞻性、观察性研究，在中西部城市的 2 家医院的内科和内科重症监护病房服务中进行，纳入了 1083 名住院的老年人，他们的医生认为他们需要做出重大医疗决策。
临床特征、医院结局、重大医疗决策的性质和代理人的参与情况。
根据医生的报告，在住院的 48 小时内，47.4%（95%置信区间，44.4%-50.4%）的老年人需要至少一些代理人的参与，包括 23.0%（20.6%-25.6%）的老年人的所有决策都是由代理人做出的。在 48 小时内至少需要 1 次代理人决策的患者中，57.2%需要关于生命维持治疗的决策（主要涉及代码状态），48.6%需要关于程序和手术的决策，46.9%需要关于出院计划的决策。需要代理人的患者经历了更复杂的医院病程，使用呼吸机的比例更高（做出决策的患者中有 2.5%，需要任何代理人决策的患者中有 13.2%；P<0.001），使用人工营养的比例更高（做出决策的患者中有 1.7%，需要任何代理人决策的患者中有 14.4%；P<0.001），住院时间更长（中位数，患者为 6 天，代理人为 7 天；P<0.001）。他们更有可能被送往长期护理机构（有患者决策的患者为 21.2%，有代理人决策的患者为 40.9%；P<0.001），医院死亡率更高（有患者决策的患者为 0.0%，有代理人决策的患者为 5.9%；P<0.001）。大多数代理人是女儿（58.9%）、儿子（25.0%）或配偶（20.6%）。总体而言，只有 7.4%的患者有生前预嘱，25.0%的患者在医疗记录中有医疗保健代表文件。
近一半的住院老年人需要代理人做出决策，包括代理人完全做出决策和患者与代理人共同做出决策。代理人通常在重症监护病房和医院病房环境中面临广泛的决策。医院功能应重新设计，以考虑代理人的重要性和日益增长的作用，支持他们做出医疗保健决策。
