The aging population has led to a greater number of older adults being hospitalized with various conditions, but many of these individuals have impaired cognition. “These patients often face major decisions about their medical care at a time when they can’t communicate their preferences or have trouble with decision making,” explains Alexia M. Torke, MD. Surrogate decision makers can be used when patients are unable to make their own medical decisions. These individuals are often close family members or friends who, in some cases, have been chosen by the patient as a healthcare power of attorney. “The presence of surrogates requires fundamental changes in the way that clinicians communicate and make decisions,” Dr. Torke says.

Much of the research on surrogates has focused on how accurately they make decisions based on hypothetical situations or has looked at the burden and distress experienced by surrogates. Few studies, however, have assessed how often surrogates are called upon to make decisions. Research is also lacking on the types of decisions surrogates must make.

Taking a Closer Look

In a study published in JAMA Internal Medicine, Dr. Torke and colleagues described the scope of surrogate decision making, the hospital course, and outcomes for adults aged 65 and older in a prospective, observational analysis. The study was conducted in medicine and medical ICU services of two hospitals and involved 1,083 patients who were identified by their physicians as requiring major medical decisions. “Our goal was to better understand the issues facing surrogates,” says Dr. Torke. This data may help redesign hospital care so that clinicians can more effectively fulfill the needs of aging patients and their families.


A Common Phenomenon

According to the findings, more than two-thirds of hospitalized older adults faced at least one major decision in the first 48 hours of being hospitalized. “Surrogate decision makers were involved in treatment decisions for 47% of older patients,” says Dr. Torke (Figure). Physician reports showed that 23% of patients had all of their medical decisions made by a surrogate when assessed at 48 hours after hospitalization, and the rest were made by the patient and surrogate together. ICU admission was associated with higher levels of surrogate decision making, but most patients who required a surrogate were admitted to the general medicine service. “This suggests that surrogate decision making is a common phenomenon in the hospital setting,” Dr. Torke notes.

Most patients who required a surrogate faced decisions about life-sustaining care, and nearly half faced decisions about procedures and operations or discharge placement (Table). Surrogate decision making generally involved patients who required high-intensity care, had more resource utilization, were more likely to be discharged to extended-care facilities, and were at a greater risk of hospital mortality. Patients who needed surrogates tended to experience a more complex hospital course. They were more likely to use ventilators and/or artificial nutrition and had longer lengths of stay. Nearly 60% of surrogates were daughters of patients, but more than 20% were either sons or spouses. Overall, fewer than 8% of patients with surrogates had a living will, and about one-quarter had a healthcare representative document in their medical record.

Significant Implications

The findings have important implications for hospital medicine and public health, says Dr. Torke. “When caring for hospitalized older adults,” she says, “clinicians should assume that they will need to partner with surrogate decisions makers and communicate with them often when making major medical decisions. This can add complexity to the communication process but has the potential to improve patient outcomes.”

Novel approaches to support decision making and communication are continuing to be explored, but Dr. Torke says these strategies should include a focus on incapacitated patients and address the role of surrogate decision makers. “It cannot be assumed that all patients will be able to provide historical information and make decisions independently,” Dr. Torke says. “Clinicians should move past the notion of considering surrogates as ‘visitors’ and view them as crucial participants in their family member’s care.”

Dr. Torke hopes that findings from her study team’s analysis can be used to develop new interventions to inform potential surrogates about what they are likely to face and to prepare them for the tasks that lie ahead. Conducting early family meetings in ICUs, giving families more time to speak during meetings, or referring surrogates to geriatric or palliative care consultations may alleviate some communication problems. “Considering that over 13 million older adults are admitted to hospitals each year,” she says, “this is an issue that is unlikely to go away and may in fact exacerbate if Americans continue to live longer.”


Torke AM, Sachs GA, Helft PR, et al. Scope and outcomes of surrogate decision making among hospitalized older adults. JAMA Intern Med. 2014;174:370-377. Available at:

Sessums LL, Zembrzuska H, Jackson JL. Does this patient have medical decision-making capacity? JAMA. 2011;306:420-427.

Torke AM, Sachs GA, Helft PR, et al. Timing of do-not-resuscitate orders for hospitalized older adults who require a surrogate decision-maker. J Am Geriatr Soc. 2011;59:1326-1331.

Shalowitz DI, Garrett-Mayer E, Wendler D. The accuracy of surrogate decision makers: a systematic review. Arch Intern Med. 2006;166:493-497.

Schenker Y, Crowley-Matoka M, Dohan D, Tiver GA, Arnold RM, White DB. I don’t want to be the one saying ‘we should just let him die’: intrapersonal tensions experienced by surrogate decision makers in the ICU. J Gen Intern Med. 2012;27:1657-1665.

Sudore RL, Fried TR. Redefining the “planning” in advance care planning: preparing for end-of-life decision making. Ann Intern Med. 2010;153:256-261.