Physicians Urged to Ask Patients to Name Health Care Proxy

CHICAGO, July 31 -- For a clinician to get a healthy patient to name a health-care surrogate, all a doctor had to do is ask, according to a study here.

Interestingly, one-third of the married participants did not name their spouse as their proxy, according to a report in the August issue of the Journal of General Internal Medicine.

In the wake of the Terri Schiavo case, physicians have "an unprecedented opportunity" to create a different paradigm for advance-care planning, said K. Michael Lipkin, M.D., of Northwestern here.

Documenting a competent patient's proxy constitutes "clear and convincing evidence" of a patient's wishes in case of incapacitation, providing a safety net until more definitive planning is accomplished, he said.

Although physician-initiated advance-care planning is desirable and effective, doctors are often reluctant to begin the necessary conversation unless patients are elderly or seriously ill, Dr. Lipkin said. Yet documenting a health-care proxy can jump-start advance-care planning, eventually leading to formal legal advance-care directives (living will, durable power of attorney) that would help keep end-of-life issues out of the courtroom.

Dr. Lipkin's survey of 309 patients was drawn from a consecutive sample of competent adult outpatients (ages 19 to 96; median age 57) visiting an outpatient eye clinic for regularly scheduled appointments. Of these, 298 (96%) completed a questionnaire while they waited to see their doctor, and all said they were ready and willing to name a health-care proxy.

Of 133 married subjects, 44 (33%) did not choose their spouse, the researchers reported. This finding is noteworthy, Dr. Lipkin said, because "physicians regularly look to spouses as informal surrogates."

When a child, sibling, or parent was chosen as a proxy, mothers, daughters, and sisters were preferred: (daughters versus sons nearly 3:1, P<0.001); sisters vs brothers (nearly 2:1 P=0.029), and nearly 5:1 for mothers vs fathers, P<0.001), Dr. Lipkin reported.

The participants were also asked to name a routine contact person in case of a current medical emergency. But when it came to the more serious task of choosing a health-care proxy, 84 (28%) chose a proxy other than the emergency contact they had named.

After the patients completed the survey, every other patient was offered an interview. Of 153 patients, only 26% said they had been asked previously to name a surrogate, and when asked whether they would want to name one "now," 87% answered "yes."

Of these participants, 28 already had a formal durable power of attorney for health care, but only eight patients were known to have a copy of their advance directive in their medical record.

Discussing the study's limitations, Dr. Lipkin said that the study population was based on a convenience sample and was not necessarily representative of the general medical population, nor were the physicians providing the patients' care necessarily representative. Also, he wrote, "we do not know how advance care planning conversations will actually be implemented in practice and the challenges that may be involved."

"When patients choose a surrogate who is not the person doctors would usually consult or who would not become empowered as a substitute decision-maker under state laws, physicians are alerted to engage these patients in an advance-care planning process that ensures the formal appointment of their desired health care agent," Dr. Lipkin said.

Most important, he added, bringing advance care planning into ordinary physician-patient interaction will make it possible to address these issues in terms of medical practice rather than as matters for the courtroom, the legislature, or executive decision.