Family Factors in End-of-Life Decision-Making: Family Conflict and Proxy Relationship

Abstract

Background: Few studies have examined proxy decision-making regarding end-of-life treatment decisions. Proxy accuracy is defined as whether proxy treatment choices are consistent with the expressed wishes of their index elder. The purpose of this study was to examine proxy accuracy in relation to two family factors that may influence proxy accuracy: perceived family conflict and type of elder-proxy relationship. Methods: Telephone interviews with 202 community-dwelling elders and their proxy decision makers were conducted including the Life-Support Preferences Questionnaire (LSPQ), and a measure of family conflict, and sociodemographic characteristics, including type of relationship. Results: Elder-proxy accuracy was associated with the type of elder-proxy relationship. Adult children demonstrated the lowest elder-proxy accuracy and spousal proxies the highest elder-proxy accuracy. Elder-proxy accuracy was associated with family conflict. Proxies reporting higher family conflict had lower elder-proxy accuracy. No interaction between family conflict and relationship type was revealed. Conclusions: Spousal proxies were more accurate in their substituted judgment than adult children, and proxies who perceive higher degree of family conflict tended to be less accurate than those with lower family conflict. Health care providers should be aware of these family factors when discussing advance care planning.

The Allied Health Care Professional's Role in Assisting Medical Decision Making at the End of Life

“…The accuracy of spouses is the highest among family proxies; it is lowest among adult children (Parks et al, 2011). Families in conflict also demonstrate lower accuracy in reporting the loved one's wishes (Parks et al, 2011).…”

“…The accuracy of spouses is the highest among family proxies; it is lowest among adult children (Parks et al, 2011). Families in conflict also demonstrate lower accuracy in reporting the loved one's wishes (Parks et al, 2011). When a proxy's beliefs are not in concordance with those of the patient, the proxy may make decisions that are more concordant with his or her own beliefs or interests than with the patient's (Moorman, Hauser, & Carr, 2009).…”

Elders’ Preferences for Life-Prolonging Treatment and Their Proxies’ Substituted Judgment

“…Substituted judgment is most accurate for the extreme health prospects (current health or poorest health) perhaps because people are most likely to have previously considered and discussed these situations with family members. Regarding types of proxies, findings have been mixed, with some studies finding family members more accurate than health care providers (e.g., Ouslander et al, 1989), some finding spouses more accurate than others (e.g., Parks et al, 2011), and yet others reporting no differences among types of proxies (e.g., Shalowitz et al, 2006;Suhl et al, 1994;Sulmasy et al, 1998;Sulmasy, Haller, & Terry, 1994;Tomlinson, Howe, Notman, & Rossmiller, 1990). Family conflict surrounding the care of a relative is also a predictor, with more conflict associated with less accurate substituted judgment (Parks et al, 2011).…”

“…Regarding types of proxies, findings have been mixed, with some studies finding family members more accurate than health care providers (e.g., Ouslander et al, 1989), some finding spouses more accurate than others (e.g., Parks et al, 2011), and yet others reporting no differences among types of proxies (e.g., Shalowitz et al, 2006;Suhl et al, 1994;Sulmasy et al, 1998;Sulmasy, Haller, & Terry, 1994;Tomlinson, Howe, Notman, & Rossmiller, 1990). Family conflict surrounding the care of a relative is also a predictor, with more conflict associated with less accurate substituted judgment (Parks et al, 2011). In light of well-documented racial differences in EOL treatment preferences and advance care planning behavior (e.g., Allen-Burge & Haley, 1997;Blackhall et al, 1999;Bullock, 2011;Caralis, Davis, Wright, & Marcial, 1993;Garrett, Harris, Norburn, Patrick, & Danis, 1993;Gessert, Curry, & Robinson, 2001;Hopp & Duffy, 2000;Johnson, Elbert-Avila, & Tulsky, 2005;Kwak & Haley, 2005;Phipps et al, 2003;Steinhauser et al, 2000), race has also been examined as a possible predictor of proxy accuracy, with some suggestion that African American proxies may be more accurate than Whites (Schmid, Allen, Haley, & DeCoster, 2009).…”

A Family-Oriented Confucian Approach to Advance Directives in End-of-Life Decision Making for Incompetent Elderly Patients

“…On the other hand, if the adult child deems the surrogate decision maker distrustful or incapable of representing the interests of one's parent, they are required by duty to persuade the parent to act in accordance with the virtue of li. 11 For an example see: Parks et al 2010. …”