PROXY DECISION-MAKERS CHOOSE LESS AGGRESSIVE END-OF-LIFE INTERVENTIONS THAN PATIENTS

Proxy decision-makers are needed for an estimated one-third of older Americans approaching death. Prior research used hypothetical illness scenarios to examine concordance between principals and their proxy decision-makers’ treatment choices, and found high disagreement and a tendency for proxy decision-makers to err toward aggressive intervention. This study used primary data collected from a severely ill patient population (N=593) at three hospitals in Massachusetts. Responses (from July 2012-January 2014) on the Physician (or Medical) Orders for Life-Sustaining Treatment (MOLST) were categorized into All Treatment (aggressive) vs. Limit Treatment (non-aggressive). Logistic regression analyses estimated the odds for aggressive treatment taking into consideration patient age, sex, race/ethnicity, severity of illness (Charlson Score), MD vs. Advanced Practice Clinician (MD vs. NP/PA), and palliative vs. non-palliative care clinicians. Over one-third (36%) chose All Treatment. Proxy decision-makers signed 43% of the forms. Mean Charlson Score was 8 (SD=3). Mean age was 71 (SD=15); 49% were male; and 83% were non-Hispanic White. Palliative care clinicians administered 50% of the MOLSTs and 48% were signed by non-MDs. A highly significant model (pseudo R 2 =0.421; p ≤ 0.001) revealed that proxy decision-makers were nearly 60% less likely to choose All Treatment compared to patient decision-makers (OR=0.43; p ≤ 0.001). This is the first known study to compare the aggressiveness of proxy vs. patient end-of-life care decisions using actual clinical choices rather than hypothetical scenarios. Hospital policy makers may wish to ensure that preferences for life-sustaining treatments are documented for patients who need proxy decision-makers to reduce the likelihood of administering unwanted treatment.