End-of-life decision-making confidence in surrogates of African-American dialysis patients is overly optimistic.

Abstract

Recent studies suggest that surrogate decision makers may be too optimistic about their end-of-life decision making abilities for loved ones. We examined surrogates' decision making confidence with an emphasis on its linkages to their understandings of patients' values and goals for end-of-life care. We used baseline data from a randomized trial with 58 dyads of African-American dialysis patients and their surrogates who separately completed the Values of Life-Sustaining Treatment Outcomes and the Goals of Care documents. Surrogates also completed a Surrogate Decision Making Confidence Scale. Overall, 60% of surrogates were unsure how their loved ones would feel about continuing life-sustaining treatment, including dialysis, in at least one of the four outcomes presented in the Values of Life-Sustaining Treatment Outcomes. For goals of care near end of life, 67.2% to 69.0% of patients preferred comfort care only, but only 20 (34.5%) surrogates were congruent with patients on Goals of Care. Nonetheless, surrogates' confidence was high (M=3.23 out of 4.0). Surrogates' confidence was positively associated with dyad congruence in values for life-sustaining treatment at only a small magnitude (Spearman's rho=.31, p=.02), but not with dyad congruence in goals of care (χ(2)=2.13, df=1, p=.19). Surrogates' confidence had little association with their actual understanding of patients' values and goals. Interventions to prepare patients and surrogates for end-of-life decision making may need to address overconfidence and help surrogates recognize their limited understanding of patients' values and goals.