Research Review

One-Half of Hospitalized Older Adults Need Surrogate Decision Makers

Nearly one-half of hospitalized American adults aged 65 and older require decision-making assistance from family members or other surrogates because the patient is too impaired to make decisions independently, according to a new study from the Regenstrief Institute and the Indiana University Center for Aging Research. The vast majority of surrogates are children or spouses, and some patients have two or more family member making decisions together.

More than 13 million older adults are hospitalized annually in the United States, and that number is projected to increase as the population ages. This means that each year, millions of family members will have to make serious decisions for a hospitalized older adult.

Surrogates will commonly face decisions about life-sustaining care, such as whether to revive a loved one if his or her heart were to stop, as well as decisions about medical procedures and whether to send the patient to a nursing facility upon discharge.

“As the population ages, family members of older adults should prepare for the crucial role they may play when their loved ones are hospitalized,” says Regenstrief Institute investigator Alexia Torke, MD, MS, an associate professor of medicine at Indiana University School of Medicine, who led the study.

A higher proportion of intensive care patients needed surrogate decision-making, but the majority of patients in the study who required a surrogate were admitted to the general medicine wards, suggesting that families are needed to make decisions throughout the hospital.

The study was published online in advance of print publication in the JAMA Internal Medicine.

The investigators followed 1,083 hospitalized older adults in either a medical intensive care unit or on the medical service of two large urban hospitals. The care of all patients required major medical decisions.

The presence of a surrogate requires fundamental changes in the way clinicians communicate and make decisions for patient, according to the study authors. They call for redesign of hospital functions to account for the large and growing role of surrogates and to provide support for surrogates as they make health care decisions.

“Many hospitals treat family members as visitors rather than as members of the patient's health care team,” Torke says. “In-depth interviews with surrogates conducted as part of my ongoing research has found that surrogates often have trouble contacting hospital staff and struggle for information about the patient. Clinicians also frequently report making decisions with surrogates to be highly stressful.”

Two-thirds of the patients in the study were female, and one-half were African American. Patients in the study who needed surrogate involvement were more seriously ill compared with those who made decisions on their own, due to the relationship between serious illness and changes in mental status for older adults, Torke says. Such patients had a more complex hospital course, longer lengths of stay and higher mortality. They were also more likely to go to a nursing home or other rehabilitation facility upon hospital discharge.

— Source: Indiana University