Let's talk: The nature of the health care surrogate-clinician relationship

INDIANAPOLIS -- A new study from the Regenstrief Institute and Indiana University School of Medicine examines the relationship between family members who make decisions for hospitalized older adults with impaired cognition and the doctors, nurses and other clinicians who care for these patients.

The researchers report that in this era of fragmented care, families rarely get to know even the names of the many clinicians who care for their family members. Even a physician or nurse who was especially supportive or helpful to the family might see the family member only once or twice. Family members usually remembered that the person was a doctor, nurse or social worker but often apologized for being unable to remember the person's name.

"The patient's care is often passed from one doctor or nurse to the next as shifts change. The patient may be getting high-quality medical care, but it is often very fragmented," said Regenstrief Institute investigator Alexia Torke, M.D., M.S., assistant professor of medicine at the IU School of Medicine.

When hospitalized older adults have impaired cognition, family members or other surrogates must communicate with clinicians to make medical decisions as well as to provide information about the patient. In interviews conducted for the study, surrogate decision-makers were clear about the kind of support they needed: frequent communication, detailed information and expressions of emotional support from the health care providers. Surrogates said they appreciated this support even when it was often delivered by clinicians they hardly knew. Surrogates expressed their distress when they had to struggle for information or couldn't get frequent updates from the clinicians.

"Surrogate decision-makers are under a lot of stress from their loved one's illness, and they crave both information and support from those caring for their family member in the hospital," Dr. Torke said.

"Surrogates want regular and coordinated updates from someone -- it doesn't have to be a physician. The health care system will have to change to meet this need, and in future studies we will be looking at how this can be accomplished," she said.

In a 2009 survey of physicians, Dr. Torke found that communication with surrogates is often delayed or infrequent. The 2012 survey of surrogates suggests that delays or lack of frequency may be a cause of distress for surrogates. The new study, "Communicating With Clinicians: The Experiences of Surrogate Decision-Makers for Hospitalized Older Adults" appears in the August 2012 issue of the Journal of the American Geriatrics Society.

The study authors surveyed 35 surrogates who recently made a major medical decision for a hospitalized older adults. Eighty percent of the surrogates were female; 56 percent were African-American and 44 percent were white. Responses did not vary by gender or race.

Surrogates' relationships with clinicians were often fragmented and brief. "Even the presence of hospitalists may not make a real difference. They work in shifts and are unlikely to have had a relationship with the patient or family prior to admission," Dr. Torke said.

The study was supported by the John A. Hartford Foundation and the National Institute on Aging (Grant # K23AG031323).

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