Older Adults without Desired Surrogates in a Nationally Representative Sample

Abstract

Background/objectives: Little is known about older adults who have intact capacity but do not have a desired surrogate to make decisions if their capacity becomes impaired.

Design: Cross-sectional study of a nationally representative sample.

Setting: National Social Life, Health, and Aging Project (NSHAP), 2005-2006.

Participants: Community-dwelling older adults without known cognitive impairment, aged 57 to 85, interviewed as part of NSHAP (n = 2,767).

Measurements: We examined demographic, medical, and social connectedness characteristics associated with answering "no" to this question: "Do you have someone who you would like to make medical decisions for you if you were unable, as for example if you were seriously injured or very sick?" Because many states permit nuclear family to make decisions for persons with no legally appointed health care agent, we used logistic regression to identify factors associated with individuals who were ill suited to this paradigm in the sense that they had nuclear family but did not have a desired surrogate.

Results: Among NSHAP respondents, 7.5% (95% confidence interval = 6.4-8.7) did not have a desired surrogate. Nearly 90% of respondents without desired surrogates had nuclear family. Compared with respondents with desired surrogates, those without desired surrogates had lower indicators of social connectedness. On average, however, they had four confidants, approximately 70% socialized at least monthly, and more than 90% could discuss their health with a confidant. Among respondents who had nuclear family, few characteristics distinguished those with and without desired surrogates.

Conclusion: Nearly 8% of older adults did not have a desired surrogate. Most had nuclear family and were not socially disconnected. Older adults should be asked explicitly about a desired surrogate, and strategies are needed to identify surrogates for those who do not have family or would not choose family to make decisions for them.

Keywords: incapacitated patients; surrogate decision-making; unbefriended.

Figure 1.

NSHAP respondents without desired surrogates. Respondent numbers are unweighted. Because respondents could have multiple relationships, the numbers of respondents with each individual relationship do not sum to the number of respondents in each category.

Figure 2.

Associations between selected factors and the absence of a desired surrogate among respondents with nuclear family. Statistically significant associations are marked with **. Because several measures of social connectedness were moderately or strongly correlated, principal components analysis was used to create two composite variables. Network structure was created from network size and density measures, and social engagement was created from community involvement and socializing measures. Values range from 0 to 1, with greater values indicating stronger network structure and greater social engagement.