The legal and ethical implications of the Indiana surrogate decision making impact on physicians and patient care in Indiana hospitals

Abstract

Background: When a patient is incapacitated and unable to make health care decisions, a surrogate decision maker must be designated to make decisions about the patient’s care in his or her place. Studies show that fewer than 20% of patients in hospitals present with a designated health care representative form. Therefore, the overwhelming majority of surrogates in hospitals are identified via default state statutes. Little is known about the implications of state default surrogate decision making statutes on physicians and patient care in clinical practice. Methods: An evaluation of state surrogate decision making statutes was conducted in order to determine variability among state laws. Additionally, a statewide, quantitative, descriptive, cross-sectional survey of a random sample of 405 physicians working in Indiana hospitals was conducted to determine: 1) physicians’ knowledge of Indiana’s surrogate decision making law; 2) physicians’ approaches to hypothetical cases they might encounter in hospital practice; and 3) any delay in patient care physicians experience as a result of state surrogate decision making laws. Results: There is very little consistency among states regarding who may serve as a surrogate decision maker. In Indiana, less than half of the surveyed physicians (47.90%) were able to correctly identify legally allowable surrogates. When presented with clinica vignettes, nearly all physicians (84.90%) report that they would allow a grandchild to act as a surrogate decision maker, even though grandchildren are not legal surrogates under the law. Additionally, more than half of physicians (53.8%) experienced a delay in patient care due to the inability to identify a legal surrogate. Conclusions: The narrow construction of state laws can leave patients in situations where they either have no qualified surrogate under the law or where they have multiple surrogates. If there are multiple surrogates with competing interests a consensus may not be reached on the patient’s medical care. These situations result in a delay of patient care. The results of this study show that the Indiana Surrogate Decision Making law is flawed as it does not reflect the composition of Indiana families and leads to delays in patient care.