Surrogates’ own values and assumptions about quality of life with dementia seem to contribute to their recommendations regarding whether patients with dementia get life-sustaining treatment (LST), according to a
study in
JAMA Network Open.
Why It’s Relevant
Spouses, children, or other surrogates often must make medical decisions on behalf of hospitalized older adults, especially when cognitive impairment is present. Such decisions can be intense, especially when involving LST, but it’s important that surrogates make the decisions the patient would want them to make.
To understand what drives surrogate decision-making, researchers created a series of vignettes in which an 85-year-old was hospitalized with a sudden, severe illness; the patient was currently unconscious but was functionally dependent before admission. Variables such as presence of an advance directive, patient sex, surrogate relationship, and intervention (e.g., stopping a ventilator or inserting feeding tubes) were randomized.
By the Numbers
- Researchers analyzed responses from nearly 6,000 participants who considered two vignettes: one in which the patient had dementia and one in which they did not.
- Respondents were less likely to endorse surrogates choosing LSTs when the patient had dementia (21.5%) than normal cognition (39.8%).
- Even when a patient had an advance directive requesting LSTs, respondents were 18.6 percentage points less likely to recommend LSTs if the patient had dementia.
- Respondents who preferred LSTs for themselves were more likely to recommend that surrogates choose LSTs.
The Other Side
The study’s vignette format presented simplified cases that do not capture the complexity or emotional strain of a real-world end-of-life decision. In addition, the vignettes did not specify the likelihood of the patient surviving, the severity of dementia, or the patient’s quality of life before admission, which also affect surrogate decision-making.
Takeaway Message
“Respondents in the current study may have been balancing concerns for quality of life and trying to prevent pain and discomfort for the patient and family in their choices or may have falsely believed that patients cannot have a good quality of life with dementia, showing a need for further education,” the researchers wrote. “[Our] results suggest that choosing a surrogate whose values align with the patient’s and discussing goals of care regularly and explicitly, especially as health changes, may promote preference-concordant decisions.”
Related Information
Source
Lauren Hersch Nicholas, et al. Surrogate decision-making for older adults with and without dementia. JAMA Network Open. Published online October 7, 2026. doi:10.1001/jamanetworkopen.2026.37691
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