Abstract
Objective
To describe the extent to which US physicians endorse substituted judgments in principle
or accommodate them in practice.
Patients and Methods
We surveyed a stratified, random sample of 2016 physicians by mail from June 25, 2010,
to September 3, 2010. Primary outcome measures were agreement with 2 in-principle
statements about substituted judgment and, after an experimental vignette that varied
the basis used by a patient's surrogate to refuse life-saving treatment, responses
indicating how appropriate it would be to overrule the surrogate's decision.
Results
Our response rate was 62% (1156 of 1875 respondents). When there is a conflict between
what a surrogate believes a patient would have wanted (substituted judgment) and what
the surrogate believes is in the patient's best interest, 4 of 5 physicians (78%)
agreed that the surrogate should base their decision on substituted judgment. Yet
we also found that 2 of 5 physicians (40%) agree that surrogates should make decisions
they believe are in the patient's best interest, even if those seem to contradict
the patient's prior wishes. In the experimental vignette, physicians were much more
likely to oppose overruling a surrogate's refusal of life-sustaining medical treatment
when that refusal was made on the basis of substituted judgment compared with when
the refusal was made on the basis of the patient's best interest (50% vs 20%; odds
ratio, 4.2; 95% CI, 2.7-6.3). Responses to the in-principle items about substituted
judgment were not consistently associated with responses to the experimental vignette.
Conclusion
US physicians largely agree, in principle, that surrogates should prioritize what
the patient would have wanted over what they believe is in the patient's best interest,
although many physicians are ambivalent in cases in which the 2 norms conflict. Even
physicians who reject the principle of substituted judgment tend to treat substituted
judgment as the preferred norm for surrogate decision making when responding to a
clinical vignette.
Abbreviations and Acronyms:
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Article Info
Footnotes
For editorial comment, see page 641.
Dr Combs is currently affiliated with the Department of Internal Medicine, UCLA Medical Center, Los Angeles, CA.
Grant Support: This study was supported by a grant from the John Templeton Foundation and the Calvin Fentress Research Fellowship , Pritzker School of Medicine, The University of Chicago (M.P.C.).
Identification
Copyright
© 2013 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.
