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 Computer
predicts wishes of incapacitated patients better
than family or loved ones
When a person fails to complete an advance
directive and becomes incapacitated by illness or injury, doctors
typically ask the patient's loved one to predict what treatment the
patient would have wanted. But a paper in PLoS Medicine reports that
a computer-based decision tool can predict a patient's treatment
wishes better than a loved one.
To use the decision tool, called a
"population-based treatment indicator," the doctor first enters the
incapacitated patient's circumstances and personal characteristics
into a computer.
Perhaps, for example, the patient has pneumonia
and severe Alzheimer disease, and he is a 60 year old, well
educated, Native American, male. The computer analyzes the treatment
preferences of similar individuals and estimates the likelihood that
the patient would want antibiotics to treat his pneumonia.
A finding that 90% of highly educated Native
American men over the age of 50 do not want to receive antibiotics
to treat pneumonia in the setting of advanced Alzheimer disease
would provide strong evidence that this patient would not want
antibiotics in these circumstances either.
David Wendler and colleagues (US National
Institutes of Health), who devised the tool,
analyzed how well the tool performs compared to
asking a loved one (loved ones are known as
"surrogates").
There is obviously no way to determine which
medical treatments patients actually want at the time they are
incapacitated, and so studies looking at whether surrogates
accurately predict patients' treatment choices must use hypothetical
scenarios. For example, one study used the following scenario:
"You recently suffered a major stroke leaving you
in a coma and unable to breathe without a machine. After a few
months, the doctor determines that it is unlikely that you will come
out of the coma. If your doctor had asked whether to try to revive
you if your heart stopped beating in this situation, what would you
have told the doctor to do?"
Analysis of 16 such studies reveals that
surrogates accurately predict patients' treatment preferences about
68% of the time. In comparison, Dr Wendler and colleagues found that
a preliminary computer-based decision tool predicted the patient's
treatment preferences with the same accuracy, and improved decisions
tools undoubtedly would be more accurate than surrogates.
Important questions remain, say the authors,
about how treatment decisions should be made on behalf of
incapacitated patients: "Do patients care more about who makes
decisions for them, or what decisions are made? Does making
end-of-life treatment decisions benefit or burden families and loved
ones overall?"
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