Using Video Images to Improve the Accuracy of Surrogate Decision-Making: A Randomized Controlled Trial

Introduction

When patients are unable to make important end-of-life decisions, doctors ask surrogate decision makers to provide insight into patients' preferences. Unfortunately, multiple studies have shown that surrogates' knowledge of patient preferences is poor. We hypothesized that a video decision tool would improve concordance between patients and their surrogates for end-of-life preferences.

Objective

To compare the concordance of preferences among elderly patients and their surrogates listening to only a verbal description of advanced dementia or viewing a video decision support tool of the disease after hearing the verbal description.

Methods

This was a randomized controlled trial of a convenience sample of community-dwelling elderly subjects (≥65 years) and their surrogates, and was conducted at 2 geriatric clinics affiliated with 2 academic medical centers in Boston. The study was conducted between September 1, 2007, and May 30, 2008. Random assignment of patient and surrogate dyads was to either a verbal narrative or a video decision support tool after the verbal narrative. End points were goals of care chosen by the patient and predicted goals of care by the surrogate. Goals of care included life-prolonging care (CPR, mechanical ventilation), limited care (hospitalization, antibiotics, but not CPR), and comfort care (only treatment to relieve symptoms). The primary outcome measure was the concordance rate of preferences between patients and their surrogates.

Results

A total of 14 pairs of patients and their surrogates were randomized to verbal narrative (n=6) or video after verbal narrative (n=8). Among the 6 patients receiving only the verbal narrative, 3 (50%) preferred comfort care, 1 (17%) chose limited care, and 2 (33%) desired life-prolonging care. Among the surrogates for these patients, only 2 correctly chose what their loved one would want if in a state of advanced dementia, yielding a concordance rate of 33%. Among the 8 patients receiving the video decision support tool, all 8 chose comfort care. Among the surrogates for these patients, all 8 correctly chose what their loved one would want if in a state of advanced dementia, yielding a concordance rate of 100%.

Conclusion

Patients and surrogates viewing a video decision support tool for advanced dementia are more likely to concur about the patient's end-of-life preferences than when solely listening to a verbal description of the disease.