Abstract
BackgroundFamily members are often required to act as substitute decision-makers when health care or research participation decisions must be made for an incapacitated relative. Yet most families are unable to accurately predict older adult preferences regarding future health care and willingness to engage in research studies. Discussion and documentation of preferences could improve proxies' abilities to decide for their loved ones. This trial assesses the efficacy of an advance planning intervention in improving the accuracy of substitute decision-making and increasing the frequency of documented preferences for health care and research. It also investigates the financial impact on the healthcare system of improving substitute decision-making.Methods/DesignDyads (n = 240) comprising an older adult and his/her self-selected proxy are randomly allocated to the experimental or control group, after stratification for type of designated proxy and self-report of prior documentation of healthcare preferences. At baseline, clinical and research vignettes are used to elicit older adult preferences and assess the ability of their proxy to predict those preferences. Responses are elicited under four health states, ranging from the subject's current health state to severe dementia. For each state, we estimated the public costs of the healthcare services that would typically be provided to a patient under these scenarios. Experimental dyads are visited at home, twice, by a specially trained facilitator who communicates the dyad-specific results of the concordance assessment, helps older adults convey their wishes to their proxies, and offers assistance in completing a guide entitled My Preferences that we designed specifically for that purpose. In between these meetings, experimental dyads attend a group information session about My Preferences. Control dyads attend three monthly workshops aimed at promoting healthy behaviors. Concordance assessments are repeated at the end of the intervention and 6 months later to assess improvement in predictive accuracy and cost savings, if any. Copies of completed guides are made at the time of these assessments.DiscussionThis study will determine whether the tested intervention guides proxies in making decisions that concur with those of older adults, motivates the latter to record their wishes in writing, and yields savings for the healthcare system.Trial RegistrationISRCTN89993391
Highlights
Members are often required to act as substitute decision-makers when health care or research participation decisions must be made for an incapacitated relative
This study will determine whether the tested intervention guides proxies in making decisions that concur with those of older adults, motivates the latter to record their wishes in writing, and yields savings for the healthcare system
Surrogates predicted patients’ treatment preferences with 68% accuracy
Summary
Members are often required to act as substitute decision-makers when health care or research participation decisions must be made for an incapacitated relative. Discussion and documentation of preferences could improve proxies’ abilities to decide for their loved ones This trial assesses the efficacy of an advance planning intervention in improving the accuracy of substitute decision-making and increasing the frequency of documented preferences for health care and research. It investigates the financial impact on the healthcare system of improving substitute decision-making. In the context of dementia research, family members are often solicited for permission to enroll a cognitively-impaired relative in a study with little likelihood of personal benefit [4,5] Such decision-making is all the more difficult when the wishes of the decisionally-impaired person have never been documented or discussed with family members. The scientific literature provides ample evidence that close relatives are unable to accurately predict elderly patients’ preferences for care [6] and willingness to engage in clinical studies of varying levels of risk and benefit [7,8,9]
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