Expanding the paradigm of the physicianʼs role in surrogate decision-making: An empirically derived framework*

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Abstract
Background: Little is known about what role physicians take in the decision-making process about life support in intensive care units. Objective: To determine how responsibility is balanced between physicians and surrogates for life support decisions and to empirically develop a framework to describe different models of physician involvement. Design: Multi-centered study of audio-taped clinician–family conferences with a derivation and validation cohort. Setting: Intensive care units of four hospitals in Seattle, Washington, in 2000 to 2002 and two hospitals in San Francisco, California, in 2006 to 2008. Participants: Four hundred fourteen clinicians and 495 surrogates who were involved in 162 life support decisions. Results: In the derivation cohort (n = 63 decisions), no clinician inquired about surrogates' preferred role in decision-making. Physicians took one of four distinct roles: 1) informative role (7 of 63) in which the physician provided information about the patient's medical condition, prognosis, and treatment options but did not elicit information about the patient's values, engage in deliberations, or provide a recommendation about whether to continue life support; 2) facilitative role (23 of 63), in which the physician refrained from providing a recommendation but actively guided the surrogate through a process of clarifying the patients' values and applying those values to the decision; 3) collaborative role (32 of 63), in which the physician shared in deliberations with the family and provided a recommendation; and 4) directive role (1 of 63), in which the physician assumed all responsibility for, and informed the family of, the decision. In 10 out of 20 conferences in which surrogates requested a recommendation, the physician refused to provide one. The validation cohort revealed a similar frequency of use of the four roles, and frequent refusal by physicians to provide treatment recommendations. Conclusions: There is considerable variability in the roles physicians take in decision-making about life support with surrogates but little negotiation of desired roles. We present an empirically derived framework that provides a more comprehensive view of physicians' possible roles.