The Stresses of Surrogate Decision-Making: Contributing Factors and Clinicians' Role in Mitigation.

BACKGROUND: Surrogate Decision-Makers (surrogates) are frequently employed in decision-making for critically ill adults. There are insufficient data considering the surrogate experience, stress, and potential for mitigation. METHODS: An anonymous online survey queried (1) medical situation (2) total stress (3) demographics (4) potential factors, including sources of information about patient wishes, external sources of support or competing stressors, and their interactions with the medical team through the experience. RESULTS: 108 respondents were included; 91 completed all items. Most respondents ranked their experience as a surrogate as one of the most stressful experiences of their lives; this was associated with whether it was an end-of-life decision (P = .003), Respondent Religion (P = .015), or religious or spiritual beliefs (P = .024), and having their own health problems (P = .008). On individual Likert responses, surrogates reported significant stress mitigation when they felt they had been helpful (P < .001), knew the patient's wishes (P = .0011), specifically discussed patient wishes (P < .001), or patient's wishes were documented (P < .001). Items about surrogate-team interaction also met significance, including the physician being communicative and available (P < .001), respectful (P = .007), honest (P < .001), and validating (P = .001). CONCLUSIONS: Surrogate stress is an evolving area for research. Significant factors included relationship with the medical team, making this an important area for HPM to play a key role in mitigating surrogate stress.

A Matter of Intent: A Social Obligation to Improve Criminal Procedures for Individuals with Dementia.

The relationship between dementia and criminal behavior perplexes legal and health care systems. Dementia is a progressive clinical syndrome defined by impairment in at least two cognitive domains that interferes with one's activities of daily. Dementia symptoms have been associated with behaviors that violate social norms and constitute criminal actions. A failure to address a gap in policies that support appropriate management of individuals with dementia reflects a failure in our social obligation to care for those who are most vulnerable amongst us. Categorical protections, informed by precedent models applied to juveniles and individuals with psychiatric illness, could help meet a social obligation to provide protections to individuals with dementia. We propose an approach that integrates affirmative defenses to mitigate criminal liability and sentencing restrictions to prevent cruel and unusual punishment.

Should Dialysis Be Stopped for an Unrepresented Patient With Metastatic Cancer?

Unrepresented patients (also referred to as unbefriended, patients alone, patients without proxy, or isolated patients) are among the most vulnerable persons entering the health care system. Legislation concerning these patients varies across the United States, resulting in disparities in care. For example, the statutory definition of who is unrepresented varies. In some states, clergy or close friends may act as surrogates; in other states, they cannot do so. Available end-of-life options also differ, creating significant disparities in end-of-life care for these patients.

It's All Relative.

In this issue of the Hastings Center Report, Daniel Brudney suggests that clinicians have an overly deferential attitude toward their patients' surrogate decision-makers that is rooted in a wrongful investment of moral authority. He maintains that surrogate decision-makers have no moral right to decide for their loved ones and that their value in the decision-making process is limited to their knowledge of their loved one's preferences. If operationalized, Brudney's framework would ease the way for clinicians to remove a surrogate who cannot provide information relevant to the patient's preferences and to resort to a paternalistic model of decision-making. Brudney fails to consider that the value of the surrogate does not flow from the surrogate, but rather from the patient's moral claim to have decisions made for him or her by a loved one. This claim recognizes that surrogates have intrinsic value through their relationship to and knowledge of the patient. Bioethics consultation services can assist clinical teams in engaging with the human crowd that surrounds each patient and navigating conflicting values and goals. This relational approach embraces the "mire and blood" that is endemic to relationships and clinical encounters.