Identifying family members who may struggle in the role of surrogate decision maker*

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Abstract
Although acting as a surrogate decision maker can be highly distressing for some family members of intensive care unit patients, little is known about whether there are modifiable risk factors for the occurrence of such difficulties. Objectives: To identify: 1) factors associated with lower levels of confidence among family members to function as surrogates and 2) whether the quality of clinician–family communication is associated with the timing of decisions to forego life support. Methods: We conducted a prospective study of 230 surrogate decision makers for incapacitated, mechanically ventilated patients at high risk of death in four intensive care units at University of California San Francisco Medical Center from 2006 to 2007. Surrogates completed a questionnaire addressing their perceived ability to act as a surrogate and the quality of their communication with physicians. We used clustered multivariate logistic regression to identify predictors of low levels of perceived ability to act as a surrogate and a Cox proportional hazard model to determine whether quality of communication was associated with the timing of decisions to withdraw life support. Results: There was substantial variability in family members’ confidence to act as surrogate decision makers, with 27% rating their perceived ability as 7 or lower on a 10-point scale. Independent predictors of lower role confidence were the lack of prior experience as a surrogate (odds ratio 2.2, 95% confidence interval [1.04–4.46], p = .04), no prior discussions with the patient about treatment preferences (odds ratio 3.7, 95% confidence interval [1.79–7.76], p < .001), and poor quality of communication with the ICU physician (odds ratio 1.2, 95% confidence interval [1.09–1.35] p < .001). Higher quality physician–family communication was associated with a significantly shorter duration of life-sustaining treatment among patients who died (β = 0.11, p = .001). Conclusions: Family members without prior experience as a surrogate and those who had not engaged in advanced discussions with the patient about treatment preferences were at higher risk to report less confidence in carrying out the surrogate role. Better-quality clinician–family communication was associated with both more confidence among family members to act as surrogates and a shorter duration of use of life support among patients who died.

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