Substitute decision-making for cognitively impaired older people.

Editorials Éditoriaux A bout 10% of elderly residents in chronic care facilities are tube-fed. Yet there is persuasive evidence that common beliefs about tube-feeding cannot be supported: tube-feeding is not similar to spoon-feeding, it is not necessarily indicated in patients with aspiration pneumonia , swallowing evaluations are not very helpful in selecting patients for tube-feeding, and when artificial nutrition and hydration are withheld or withdrawn patients do not have a painful death. 1 So why are patients tube-fed? In this issue (page 1705) Drs. report on their timely study of decision making for long-term tube-feeding in cognitively impaired elderly people. 2 Their study raises a number of crucial issues around substitute decision-making and the ethics of tube-feeding and suggests that some physicians may be failing patients and their substitute decision-makers by not informing them of research findings that contradict popular beliefs about common interventions. Is it possible that these physicians are unaware of such disputes or that they choose to disregard them? Mitchell and Lawson interviewed 46 substitute decision-makers who had agreed to tube-feeding for their elderly dependents and found that 78.3% had some sort of discussion with the primary care physician, the consultant who inserted the feeding tube, or a resident or intern. The substitute decision-makers stated that the medical benefits most often mentioned to them were the prolongation of life and the prevention of aspiration. However, Mitchell and Lawson cite studies that do not support these claims. Perhaps the 22% of participants in their study who had had no discussion with medical personnel were better off after all: at least they had not been misled. In all, 39% of the substitute decision-makers in the study felt that the physician had made the decision alone, and 28% indicated that the doctor had shared the decision. Yet only 13% were not closely related to the patients. It seems highly spurious to suppose that the other 87% had so little knowledge of their family values and preferences that they would have lacked confidence in their own judgement unless they had been otherwise advised or persuaded. Advance directives or living wills would certainly be of help to substitute decision-makers, but the limitations of living wills should be recognized. Singer 3 recommends giving specific directives about health care and personal matters. In addition, he advises that a person appoint a trusted friend or family member to act as proxy or substitute decision maker. …