Can we improve treatment decision-making for incapacitated patients?

Rid A, Wendler D (2010): Can we improve medical treatment decision-making for incapacitated patients? Hastings Center Report 40(5): 36-45

Clinical practice relies on patients to make their own treatment decisions, typically in consultation with a clinician. This approach is intended to respect those who can make decisions but poses a dilemma for incapacitated patients, such as those with advanced Alzheimer disease. This dilemma is widespread. In the United States, approximately half of all decisions regarding life-sustaining treatment for nursing home residents and three-quarters of decisions for hospitalized patients with life-threatening illnesses involve incapacitated patients. These situations pose significant challenges, especially when it is unclear which treatment the patient prefers, and which treatment best promotes the patient’s clinical interests. For example, should clinicians intubate a patient with moderate Alzheimer disease who has no advance directive and develops pneumonia? Current practice in these cases is to rely on the patient’s surrogate to make treatment decisions in consultation with the patient’s clinicians. Patients sometimes designate a surrogate using a durable power of attorney. State statutes identify next-of-kin surrogates for incapacitated patients who did not appoint a surrogate.

This practice has been in place for more than two decades now, yet there have been no systematic evaluations of how well it promotes the most important ethical goals relevant to making treatment decisions for incapacitated patients. We describe these goals and argue that current practice systematically fails to promote them. Then we consider ways to improve current practice. Incorporating empirically grounded predictions about the individual patient’s treatment preferences into the shared decision-making process offers the greatest potential.