Journal of Advanced Practices in Nursing

Challenges in Determining the Substitute Decision Maker: Findings from an Australian Intensive Care Unit

Abstract

Mendoza JL, Burns CM

Background: Little research has been undertaken to explore how Substitute Decision Makers (SDM) are chosen by patients and especially for incompetent adults in an intensive care unit (ICU). Objective: To determine how substitute decision makers are chosen in ICU. Method: A retrospective cohort study using a clinical file audit to appraise socio-demographic and qualitative data from the medical record. The data from the medical record was collected by one researcher and analysed using a de-identified file. Ethics approval was sought and granted by the hospital Ethics Committee and the research was deemed to be low risk due to the nature of the retrospective file audit. Setting/Participants Patients admitted to ICU between July 2010 and June 2011 (n=1500) and died within ICU (n=236). The social demographic features were analysed using descriptive statistics and analysis using SPSS statistical software. Results: Most patients who died in ICU (70%) were aged over 60 years. While most widowed people and some married persons nominated an adult child as next of kin (NOK), 34% of single people nominated someone other than a family member as next of kin. The audit showed key differences between next of kin and the nominated substitute decision maker. For example, in all age groups, for those nominating a partner as next of kin (n=124) over a third had a different person assume the role of substitute decision maker. Conclusion: This retrospective study found that one third of patients preferred another trusted advocate to assume the role of substitute decision maker rather than their next of kin. Hence, the NOK of patients admitted to ICU should not be assumed to be their preferred substitute decision-maker. We recommend a community education program to raise awareness for families to begin conversations about preferences for substitute decision makers especially amongst ageing family members.