Surrogate Perspectives on a Patient Preference Predictor: Good Idea, But I Should Decide How It Is Used

Abstract Objective: Current practice frequently fails to provide care consistent with the preferences and values of decisionally-incapacitated, critically ill patients. It also imposes significant emotional burden on their surrogates. Algorithmic-based patient preference predictors (PPPs) have been proposed as a way to address these two concerns. While previous research found that patients strongly support the use of PPPs, the views of surrogates are unknown. This study assesses the views of experienced surrogates regarding the use of PPPs as a means to improve treatment decision making for incapacitated patients.Setting: Two academic medical centers and two community hospitals.Subjects: Experienced Surrogates [n=26].Interventions: An initial quantitative survey followed by an in-depth interview and a final quantitative survey.Measurements: Overall level of support for PPPs and views on how a PPP should be used, if at all, in practice.Main Results: Overall, 21 participants supported the use of PPPs. The remaining five indicated that they would not use a PPP because they made decisions based on the patient’s best interests, not based on which treatments the patient would choose for themselves. Some respondents expressed concern that PPPs might be used to deny expensive care or be biased against minority groups. Finally, 24 respondents indicated that surrogates, not patients, should decide how treatment decisions are made, including whether and how to use PPPs.Conclusions: Surrogates, like patients, strongly support the use of PPPs as a means to improving decision-making for incapacitated patients. These findings provide support for developing a PPP and assessing its use in practice. At the same time, patients and surrogates disagree over whose preferences should determine how treatment decisions, including whether to use a PPP, are made. These findings reveal a fundamental disagreement regarding the guiding principles for surrogate decision-making that need to be addressed by attempts to improve current critical care practice.