Veterans’ End-of-Life Preferences Not Well-Communicated to Surrogates

By Brenda L. Mooney

Alan Makhoul, a Duke University student and volunteer at the Durham, NC, VAMC’s Hero’s Way Hospice Unit visited last year with Army Veteran Joe Bradford. Photo by Linnie Skidmore of the Durham VAMC

NEW HAVEN, CT — With a substantial number of older patients treated at the VA—more than 2 million World War II and Korean War veterans were among the patient population in 2015—how to manage their end-of-life care is an increasingly critical question.

The problem identified by a new study, however, is that few older veterans plan ahead for end-of-life medical decisions. And, even for those who do, many don’t do a very good job of communicating their preferences to family members or friends who serve as surrogates.

Previous research has demonstrated that surrogates often lack the knowledge they need to make decisions for patients, but a new study, published by the Journal of the American Geriatrics Society, is the first to examine the issue from both the patient and surrogate perspective.1

For the study, Yale University researchers interviewed 350 veterans 55 years of age or older, while separately interviewing the family members or friends chosen as surrogates by the veterans.

Treatment goals were assessed by veterans’ ratings of three health states: severe physical disability, cognitive disability, and pain, as an acceptable or unacceptable result of treatment for severe illness.

Surrogates then were questioned about whether the patient would prefer treatment, even if they were left severely impaired physically, cognitively or in severe pain. They were considered to have accurate knowledge if they correctly predicted all three responses.

Veterans and surrogates also were asked about living will and healthcare proxy completion and the level of communication about life-sustaining treatment and quality vs. quantity of life (QOL).

Results indicate that more than 40% of the pairs—veterans and surrogates—agreed that the veteran had not completed a living will or health care proxy and that there was no QOL communication. For each activity, meanwhile, 18-34% disagreed about participation.

In the pairs who agreed QOL communication had occurred, 30% of surrogates had knowledge, compared to 21% who agreed communication had not occurred and 15% who disagreed.

Researchers pointed out that, overall, only 20% of surrogates could accurately predict the patient’s wishes for life-sustaining treatment, which was only slightly better among pairs who had agreed they had communicated than those who did not agree.

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