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Surrogates and Doctors Often Disagree on Prognosis

06/01/2016

A research report in the Journal of the American Medical Association found that family members who are surrogate decision makers for patients are frequently more optimistic about outcomes than physicians are. The authors of the study feel that this is the result of the beliefs and personalities of the family members, and not a misunderstanding of the prognosis given to the patient. Most surrogates explained that they feel that having hope helped the patient. Others sited their religious beliefs and their more intimate knowledge of the patient. The researchers call for physicians to communicate with patients and families in ways that better understand their needs.

The survey and structured interviews used by the researchers showed that surrogates often experience conflicting feelings about “bad news.” They say they want doctors to share that news with them, and they also say that it is difficult to hear. There is evidence that “physicians offering an optimistic outlook are perceived by patients and families as more compassionate and skillful than pessimistic physicians.”

The researchers found that slightly over half of the surrogates disagreed with physicians on important issues, such as whether it was likely that the person would ever leave the hospital. A significant minority also misunderstood the physician’s prognosis, and many disagreed with it as well. While twenty percent of the surrogates were more pessimistic than physicians, most were more optimistic than the doctors. Surrogates were a little more accurate than a random guess at predicting what would happen to their loved one. Doctors’ prognoses were much more accurate.

Surrogate decision makers’ optimism can cause them to choose treatments whose “burdens exceed benefits and to delay initiation of palliative care.” In order to combat this, the authors of the JAMA article suggest that doctors must address the emotional state of surrogates before they impart information. Otherwise their listeners may not be able to absorb and process what they are being told. Doctors who show empathy, and listen to the values and wishes of the family, also facilitate better understanding for family members. The amount of uncertainty in the prognosis should also be communicated honestly with surrogates.

The job of a physician is “not simply to relay information but to optimize the ability of surrogates to hear, absorb, integrate, and use information including clinicians’ expectations with regard to important outcomes.” If there is discordance between the physician’s prognosis and what the surrogate decision maker expects, the authors say that best way to address it is to ask open-ended questions to reveal the source of the difference. Listening well to family members will allow the physician to “provide the psychological and other support that most families need to process information and share in decisions that honor patients’ values, goals, and preferences.”

Overall, the study highlights the complexity of interactions, the variances in ways patients and families process “bad news,” and the importance of the work of the surrogate decision makers. The challenging task of delivering serious healthcare information, says the article, may be best managed by beginning with asking questions rather than offering prognosis. “‘What is your understanding of what the clinical team expects to happen?’ or ‘What has the team told you about what they expect?’ If the answer includes prognostic expectations that differ from those of the physician, the best response may be an open-ended inquiry to help identify the source of the discordance.”

Sources: (Journal of the American Medical Association, 05/17, jama.jamanetwork.com/article.aspx?articleID=2521947; Journal of the American Medical Association, 05/17, jama.jamanetwork.com/article.aspx?articleid=2521967; Health Day, 05/17, consumer.healthday.com/senior-citizen-information-31/misc-death-and-dying-news-172/how-much-time-is-left-doctors-loved-ones-often-disagree-711066.html; Los Angeles Times, 05/17, www.latimes.com/science/sciencenow/la-sci-sn-critical-illness-hope-trumps-prognosis--20160517-snap-story.html)