The Gerontologist

cite as: Gerontologist, 2018, Vol. 00, No. 00, 1–11

doi:10.1093/geront/gny042
Advance Access publication May 17, 2018

Research Article

Surrogate Preferences on the Physician Orders for Life-

Sustaining Treatment Form
Elizabeth E. Chen, PhD,1,* Charles T. Pu, MD,2 Rachelle E. Bernacki, MD,3 Julia Ragland, MD,4
Jonathon H. Schwartz, MD,5 and Jan E. Mutchler, PhD6
The Gerontology Institute, University of Massachusetts Boston. 2Partners HealthCare, Boston, Massachusetts.
1

Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts. 4Newton-Wellesley
3

Hospital, Newton, Massachusetts. 5Spaulding Hospital for Continuing Care, Cambridge, Massachusetts. 6Gerontology
Department and Institute, University of Massachusetts Boston.
*Address correspondence to Elizabeth E. Chen, PhD, Gerontology Institute, University of Massachusetts Boston, Boston, MA 02125. E-mail:
Elizabeth.E.Chen@gmail.com

Received: October 29, 2017; Editorial Decision Date: April 9, 2018

Decision Editor: Rachel Pruchno, PhD

Abstract
Background and Objectives: The purpose of this study is to compare treatment preferences of patients to those of surro-
gates on the Physician Orders for Life-Sustaining Treatment (POLST) forms.
Research Design and Methods: Data were collected from a sequential selection of 606 Massachusetts POLST (MOLST)
forms at 3 hospitals, and corresponding electronic patient health records. Selections on the MOLST forms were categorized
into All versus Limit Life-Sustaining Treatment. Multivariable mixed effects (grouped by clinician) logistic regression mod-
els estimated the impact of using a surrogate decision maker on choosing All Treatment, controlling for patient characteris-
tics (age, severity of illness, sex, race/ethnicity), clinician (physician vs non-physician), and hospital (site).
Results: Surrogates signed 253 of the MOLSTs (43%). A multivariable logistic regression model taking into consideration
patient, clinician, and site variables showed that surrogate decision makers were 60% less likely to choose All Treatment
than patients who made their own decisions (odds ratio = 0.39 [95% confidence interval = 0.24–0.65]; p < .001). This
model explained 44% of the variation in the dependent variable (Pseudo-R2 = 0.442; p < .001); mixed effects logistic regres-
sion grouped by clinician showed no difference between the models (LR test = 4.0e-13; p = 1.00).
Discussion and Implications: Our study took into consideration variation at the patient, clinician, and site level, and
showed that surrogates had a propensity to limit life-sustaining treatment. Surrogate decision makers are frequently needed
for hospitalized patients, and nearly all states have adopted the POLST. Researchers may want study decision-making pro-
cesses for patients versus surrogates when the POLST paradigm is employed.
Keywords: End-of-life care, Palliative care, Advance care planning

The Physician Orders for Life-Sustaining Treatment
(POLST) paradigm offers a structured approach for physi-
cians, nurse practitioners, and physician assistants to dis-
cuss and document patient preferences for life-sustaining
treatments. The POLST is not a substitute for advance
directives, which are meant to name a surrogate decision
maker and describe care preferences for future, unknown
medical situations (National POLST Paradigm, 2017b). The
Institute of Medicine recommends the POLST when disease
advances and when patients are facing their final year of
life (Institute of Medicine, 2014). If a patient needs a sur-
rogate decision maker, such as in situations when a patient
is deemed by a physician to be temporarily or permanently
“not competent” to make medical decisions (Drane, 1984),

© The Author(s) 2018. Published by Oxford University Press on behalf of The Gerontological Society of America. 1
All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Downloaded from https://academic.oup.com/gerontologist/advance-article-abstract/doi/10.1093/geront/gny042/4998924

by university of winnipeg user
on 24 May 2018
 2 The Gerontologist, 2018, Vol. 00, No. 00
the POLST reflects preferences resulting from discussions
between clinicians and patients’ surrogates.
The POLST Form is a medical order and is transferrable
across care settings; this is particularly helpful given that
individuals in the last 6 months of life are often under the
care of more than 10 different physicians across multiple
settings (Dartmouth Institute for Health Policy and Clinical
Practice, 2014). Program efficacy studies indicate that the
POLST improved documentation in medical records about
end-of-life care, and that terminal interventions were largely
consistent with documented preferences (Hickman et al.,
2009; Hickman et al., 2011; Richardson, Fromme, Zive,
Fu, & Newgard, 2014; Schmidt, Hickman, Tolle, & Brooks,
2004; Tolle, Tilden, Nelson, & Dunn, 1998). The POLST
paradigm has been, or is in the process of being imple-
mented in 48 states (National POLST Paradigm, 2017a),
and its use will likely grow in the coming years along with
the numbers of individuals aging with chronic illness.
Previous research using POLST data showed that a
majority of completed POLST records indicate a preference
to limit life-sustaining treatments (Fritz & Barclay, 2014;
Fromme, Zive, Schmidt, Cook, & Tolle, 2014; Fromme,
Zive, Schmidt, Olszewski, & Tolle, 2012; Hammes,
Rooney, Gundrum, Hickman, & Hager, 2012; Hickman,
Keevern, & Hammes, 2014; Kim, Ersek, Bradway, &
Hickman, 2015; Schmidt, Zive, Fromme, Cook, & Tolle,
2014; Tarzian & Cheevers, 2017; Tolle et al., 1998) even
though the POLST allows patients or surrogates to indi-
cate a preference to apply all treatment. One reason for the
large proportions preferring to limit treatment may be due
to clinicians’ interpretation of the need for a POLST form;
that is, administering full treatment to sustain life is the
default situation, and POLST forms are thus only needed
if individuals prefer treatment limitations. Another reason
may be attributed to study populations, largely comprised
of non-Hispanic White individuals, who are more likely to
prefer treatment limitations than those from minority pop-
ulations (Rahman, Bressette, Gassoumis, & Enguidanos,
2016). Studies have not examined treatment preferences
when surrogates or health care proxies make decisions
documented on POLST forms.
Almost one-half of hospitalized older adults use a sur-
rogate decision maker; and three out of four physicians in
a hospital sample reported that they have made a major
decision with a surrogate in the past 30 days (Torke et al.,
2014; Torke, Siegler, Abalos, Moloney, & Alexander, 2009).
Guidance from the American Medical Association (2016)
recommends that physicians guide surrogates to employ
the ethical principle of “substituted judgment,” that is, to
choose the treatment path the patient would have chosen
if he or she were able. However, researchers have ques-
tioned the accuracy of substituted judgment for more than
25 years, and have shown in experimental vignettes that
surrogates are largely unable to predict patient decisions
about life-sustaining treatments (Barrio-Cantalejo et al.,
2009; Hinderer, Friedmann, & Fins, 2015; Seckler, Meier,
Downloaded from https://academic.oup.com/gerontologist/advance-article-abstract/doi/10.1093/geront/gny042/4998924
by university of winnipeg user
on 24 May 2018
Mulvihill, & Cammer Paris, 1991; Shalowitz, Garrett-
Mayer, & Wendler, 2006; Suhl, Simons, Reedy, & Garrick,
1994; Torke, Alexander, & Lantos, 2008). When there is
no evidence of what a patient would have wanted, clini-
cians may apply the “best interest” standard, which is
based on the “the pain and suffering associated with the
intervention,” “the degree of and potential for benefit,”
and “impairments that may result from the intervention”
(American Medical Association, 2016).
There is evidence of strong correlation between proxy
and self-reports for observed behaviors, such as walking
limitations after a stroke (Powell, Johnston, & Johnston,
2007) and quality of life measures associated with physi-
cal functions, such as breathing, hearing, sleeping (Elliott,
Lazarus, & Leeder, 2006). Socio-demographic characteris-
tics and the type of chronic conditions can confound results,
but controlling for these confounders has confirmed that
proxy reports are accurate for observable behaviors, such
as the ability to walk a certain distance, but potentially
inaccurate for subjective behaviors, such as the ability to
manage money or unobserved behaviors, such as difficulty
in using the toilet (Li, Harris, & Lu, 2015).
Specific to patients nearing the end of life, family mem-
bers can be reliable proxy reporters of objective quality of
life measures, such as walking, nausea, and vomiting, but
with mixed results for subjective measures, such as fatigue
or pain. Further, when there is a discrepancy, proxies tend
to report worse subjective quality of life than patients (Ferri
& Pruchno, 2009; Kirou-Mauro, Harris, Sinclair, Selby, &
Chow, 2006; Kutner, Bryant, Beaty, & Fairclough, 2006;
Novella et al., 2001). In a sample of patients in an inpa-
tient palliative care unit, proxy family or physician reports
of patient symptoms were poorly correlated with patient
reports during early hospitalization (Day 3), improved over
time (Day 6), but were still low (<35% agreement) on meas-
ures of physical symptoms and psychological well-being
(Jones et al., 2011). Family caregivers tended to overesti-
mate the intensity or frequency of lack of energy, anxiety,
sadness, and pain distress compared with patients. On the
other hand, physicians generally underestimated symptom
burden compared with patients (Oechsle, 2013).
Concept Model
This study is designed to estimate the odds that surrogate deci-
sion makers’ would choose aggressive life-sustaining treat-
ment, taking into account patient, clinician, and upstream
factors that might have channeled patients to sites of care.
We incorporated patient variables to take into account fac-
tors that may influence whether a patient needed a surrogate,
such as age and severity of illness, which may also affect pref-
erences (Figure 1). On the other hand, clinician type, patient
race/ethnicity, and sex were thought to affect only preferences.
We acknowledge that prior decisions might have influenced
a patient’s site of care, such as insurance limitations, patient
or clinician preferences, and geography. These factors, in
 The Gerontologist, 2018, Vol. 00, No. 00
Figure 1. Concept model—factors affecting life-sustaining treatment
preferences for hospitalized adults with limited life expectancy.
addition to site-associated practice norms and prior advance
care plans, could affect patient or surrogate preferences for
life-sustaining treatments in ways that were not measured.
Methods
The Institutional Review Board at Partners HealthCare
approved this study, which uses 606 patient records from
three of its hospitals. Research Electronic Data Capture
(REDCap), an electronic data capture tool hosted by the hos-
pital system’s research management office, was used to col-
lect and manage study data (Harris, Taylor, Payne, Gonzalez,
& Conde, 2009). De-identified data were exported for anal-
ysis using STATA 13.1 (StataCorp. 2013, 2013).
Setting Characteristics
The three hospital sites were part of the same integrated care
network, and were among the first hospitals to implement
Massachusetts POLST (MOLST) in Eastern Massachusetts.
As the first hospitals to implement MOLST, our data rep-
resent de novo exposure to MOLST, and nearly eliminates
the possibility that patients had arrived with a form com-
pleted at another hospital or in an outpatient setting.
Each site employed a slightly different staffing model, and
differed as to how broadly the MOLST was deployed. Site 1,
a long-term acute care hospital (LTACH), was staffed largely
by employed physicians and augmented by a few nurse
practitioners; none were trained in palliative care. MOLST
was implemented throughout the entire 180-bed hospital,
where all patients were admitted directly from an acute care
hospital stay. LTACHs serve patients with severe illness,
who need hospital-level care for a long stay, which may
last one or more months (American Hospital Association,
2017; Center for Medicare and Medicaid Services, October
2016). Thirty-one different clinicians signed MOLSTs at
Site 1. Site 2 is a community hospital, where MOLSTs were
largely administered by a consulting palliative care prac-
tice comprised of five palliative care physicians and nurse
Downloaded from https://academic.oup.com/gerontologist/advance-article-abstract/doi/10.1093/geront/gny042/4998924
by university of winnipeg user
on 24 May 2018
3
practitioners, who signed nearly all (96%) of the forms;
another five clinicians outside of this palliative care practice
signed the remaining 4% of the forms at this location. Site 3
is an inpatient intensive palliative care unit with 12 beds in
a quaternary care academic medical center with more than
800 beds. This inpatient palliative care unit was staffed by
employed physician assistants under the direction of a small
number of palliative care physicians. Eleven different clini-
cians completed MOLSTs at Site 3.
Patient selection also differed from site to site, but all
patients had advanced illness and were nearing the end of
life. At Site 1 (LTACH), clinicians used the “surprise” ques-
tion, which has been validated in a number of settings as a
simple prognostic tool for patients with limited life expec-
tancy (Da Silva Gane, Braun, Stott, Wellsted, & Farrington,
2013; Javier et al., 2017; Moss et al., 2008; Vick, Pertsch,
Hutchings, Neville, & Bernacki, 2016). That is, clinicians
asked themselves “Would I be surprised if this patient
died in the next 12 months?” A “no” triggered a “goals
of care” conversation, followed by documentation on a
MOLST form. Monthly tracking data over the first year of
MOLST implementation at Site 1 showed that 15%–40%
of discharged patients completed MOLSTs. The palliative
care consulting practice (Site 2) did not use the “surprise”
question for patients, but nearly all patients would have
qualified had it been employed. Site 3, the inpatient pal-
liative care unit, did not always use the “surprise” ques-
tion because nearly all patients were expected to have less
than 1 year of remaining life. Clinicians completed MOLST
forms only for patients who were discharged to another
care setting or to home, which accounted for approximately
50% of patients at this site. Despite differing patient selec-
tion criteria, patients at all sites with a completed MOLST
were expected to have limited life expectancy.
Sample
The sample comprised a sequential selection of patients
who had completed the Massachusetts Medical Orders for
Life-Sustaining Treatment (MOLST) forms while inpatient
at three hospitals between July 9, 2012 and January 17,
2014. The final analytic data set contained 593 MOLST
forms after discarding 2% (N = 13 from 606) with miss-
ing clinician signatures, making the order invalid. Two-
hundred and eighty-eight (N = 288; 49%) of the analytic
data set came from the LTACH (Site 1); 204 (34%) from
the palliative care consulting practice at a community hos-
pital (Site 2); and 101 (17%) from the inpatient intensive
palliative care unit at the academic medical center (Site
3). The sample comprised patients in both intensive care
(ICU) and non-intensive care units, and residing in both
long-term care settings and in the community. A small num-
ber of patients completed multiple MOLST forms during
1 hospital stay, or completed another MOLST form dur-
ing a second or third hospitalization over the course of the
study period. In these circumstances, data were collected
 4 The Gerontologist, 2018, Vol. 00, No. 00

only from the first MOLST, reserving the issue of changes
to MOLST forms for another study.
Dependent Variable
The dependent variable (All vs Limit Treatment) was
constructed from responses on Page 1 of the MOLST
form, which provided a sequence of dichotomous “do
not attempt” or “attempt” choices beginning with resus-
citation, followed by ventilation, then transfer to a hos-
pital (Massachusetts Medical Orders for Life Sustaining
Treatment, 2014). Page 2 of the form seeks preferences
about the duration of treatments on Page 1, and offers
an opportunity to specify decisions regarding other life-
sustaining treatments, such as kidney dialysis and artificial
nutrition or hydration. Page 2 is not required in order for
the MOLST to be valid, and too few were completed for
meaningful analysis.
The pattern of responses generally followed logically
from the first choice, resuscitation (Figure 2). Ventilation
options were divided into two categories: invasive (intuba-
tion) and noninvasive, such as continuous positive airway
pressure (CPAP); information about CPAP was not used
due to the large number (N = 119; 20%) of forms miss-
ing these data. Patients were grouped into those who pre-
ferred All Treatment (“Yes” to resuscitation, intubation,
AND transfer) or Limit Treatment (“No” to resuscitation,
intubation, OR transfer). A separate analysis confirmed
that there was no significant difference between the group
missing CPAP data and the group not missing CPAP data
for the primary variable of interest (surrogate vs patient
decisions; Pearson χ2 = 0.21; p = .644; Supplementary
Table 1).
Severity of Illness
We used ICD-9 codes associated with the hospitalization
during which the MOLST form was signed to compute
the Charlson Score as an indicator of illness severity (Al
Feghali et al., 2016; Chang et al., 2016; Tremblay, Arnsten,
& Southern, 2016). The Charlson Weighted Index of
Comorbidity was developed as a prognostic indicator for
individuals with chronic illnesses. Each chronic illness on the
Index has a score associated with mortality risk (1, 2, 3, or 6;
Charlson, Pompei, Ales, & MacKenzie, 1987). For example,
uncomplicated diabetes is 1, diabetes with end organ damage
is 2, moderate or severe liver disease is 3, and metastatic solid
tumor is 6. Scores for comorbid conditions are summed. In
the original Charlson validation cohort, 1-year mortality was
100% for patients who were hospitalized, survived to dis-
charge, and had a score greater than 5 (Charlson et al., 1987).
Survival has improved since the original Charlson validation
cohort for many illnesses captured by its Index, but the tool
remains useful in research as a measure for burden of illness
(Crooks, West, & Card, 2015; D’Hoore, Sicotte, & Tilquin,
1993). Some studies have incorporated a decade-based age
adjustment specified by Charlson to reflect additional mor-
tality risk associated with age beginning at age 50 (Charlson
et al., 1987; Dias-Santos, Ferrone, Zheng, Lillemoe, &
Fernandez-del Castillo, 2015; Kaesmann, Janssen, Schild, &
Rades, 2016; Lorenzon et al., 2017; St-Louis et al., 2015).
Conceptually, this adjustment was meant to reflect that the
same illness in a 50-year-old and an 80-year-old represent

Main Effect
Data for the main variable of interest (patient or surrogate
signature) were collected from the MOLST form, which
requests that signatories identify their relationship to the
patient. If the signatory did not respond, we compared the
patient name with the signature and associated printed
name. Forms with different signatory and patient names
were categorized into the surrogate group. All printed
names were legible.

Control Variables
Patient Demographics
Demographic data were obtained from patient electronic
health records, which included age at the time the MOLST
was signed and patient race/ethnicity. Logistic regression
models employed a categorical age variable approximat-
ing the bottom quartile (<60), interquartile range (60–73),
and top quartile (80 and over) at Site 1, where there was
the most variation between preferences for All versus Limit
Treatment. Figure 2. Pattern of responses on MOLST.

Downloaded from https://academic.oup.com/gerontologist/advance-article-abstract/doi/10.1093/geront/gny042/4998924

by university of winnipeg user
on 24 May 2018
 The Gerontologist, 2018, Vol. 00, No. 00 5

different risks for 1-year mortality. We did not include this palliative care practices were presented with an option for
adjustment, which is based on age decade, to allow for greater palliative care and accepted, which may be associated with a
precision using our age variable. willingness to accept limitations to life-sustaining treatment.

Clinician Type
Clinician certification (physician vs nurse practitioner or
physician assistant) was collected from signatures on the
MOLST forms. If certification data were missing, then a
research assistant matched the signature against internal
staffing records.
Site
The variables Site 1, Site 2, and Site 3 identified each hospital,
and served as a means to hold constant site-associated prac-
tice variation, such as differing staffing models and the use
of palliative care specialists. The Site variable also took into
account unmeasured factors that may have channeled patients
to each site, such as insurance coverage and patient or clini-
cian preferences farther upstream in the care continuum. For
example, patients at the LTACH may not have been offered
palliative care, or were offered the service and refused; as a
result, these patients were transferred to the LTACH for high
intensity treatment. Patients under the care of clinicians in the
Statistical Analysis
We examined sample characteristics by site and by deci-
sion maker using the Pearson χ2 test. Single-variable logis-
tic regression analyses were first performed to estimate the
odds that each independent variable would predict a pref-
erence for All (vs Limit) Treatment. Multivariable logistic
regression models estimated the odds for All Treatment
first for Surrogate (vs Patient) Decision Makers, followed
by patient characteristics, then concluding with the impact
of Site. Mixed effects logistic regression was performed
using STATA’s xtmelogit command to account for covari-
ance due to clustering of patients within clinicians.
Results
Baseline Patient Characteristics
Nearly all patient characteristics differed between sites
(Table 1). Surrogates signed approximately 35% of the

Table 1. Sample Characteristics by Site and by Treatment Preference Group

MOLSTb signature

Site 1a Site 2a Site 3a Surrogate Patient

N = 593 (N = 288) (N = 204) (N = 101) (N = 253) (N = 340)

All (vs Limit) life-sustaining treatment 199 (69%) 5 (3%) 12 (12%) 58 (23%) 158 (46%)***
Surrogate decision maker 100 (35%) 119 (58%) 34 (34%) 253 (100%) —
Patient age: median (range) 68 (20–93) 83 (42–102) 60 (24–87) 80 (24–102) 68 (20–100)***
Patient age group
<60 69 (24%) 12 (6%) 50 (50%) 43 (17%) 88 (26%)**
60–79 152 (53%) 52 (25%) 41 (41%) 76 (30%) 169 (50%)***
80 and over 67 (23%) 140 (69%) 10 (10%) 134 (53%) 83 (24%)***
Charlson Scorec: median (range) 5 (0–12) 5 (0–15) 7 (2–10) 5 (0–12) 6 (0–15)*
Male (vs female) patient 162 (56%) 83 (41%) 48 (48%) 124 (49%) 169 (50%)
Race/ethnicity of patient
Non-Hispanic White 214 (74%) 191 (94%) 87 (86%) 282 (83%) 210 (83%)
Non-Hispanic Black 17 (6%) 1 (<1%) 5 (5%) 9 (4%) 14 (4%)
Non-Hispanic other and Hispanic 57 (20%) 12 (6%) 9 (9%) 34 (13%) 44 (13%)
Physician (vs NP or PA) 179 (62%) 115 (56%) 13 (4%) 135 (53%) 172 (51%)
Primary diagnoses (top 5)
Cancers 29 (11%) 87 (26%)***
Cardiovascular diseases 44 (17%) 45 (13%)
Respiratory disease/dysfunction 40 (17%) 52 (15%)
Infection/non-specific fever 34 (13%) 40 (12%)
Gastrointestinal disease/dysfunction 18 (7%) 18 (5%)

Notes: MOLST, Massachusetts Physician Orders for Life-Sustaining Treatment.

a
Site 1: 180-bed long-term acute care hospital with no palliative care specialist; Site 2: Palliative care consulting practice in 300-bed community acute care teach-
ing hospital; Site 3: Inpatient palliative care unit in 800+ bed academic medical center. bMassachusetts Medical Orders for Life-Sustaining Treatment Form.
c
Score derived from the Charlson Weighted Index of Comorbidities using discharge diagnoses (ICD-9) and does not incorporate the decade-based age adjustment
described in the original Charlson (1987) paper.
p-Value using the two-sample test of proportion comparing Surrogate and Patient groups: *≤0.05; **≤0.01; ***≤0.001.

Downloaded from https://academic.oup.com/gerontologist/advance-article-abstract/doi/10.1093/geront/gny042/4998924

by university of winnipeg user
on 24 May 2018
 6 The Gerontologist, 2018, Vol. 00, No. 00

MOLST forms at Sites 1 (LTACH without palliative care)
and 3 (palliative care at academic medical center) compared
with 60% at Site 2 (palliative care at community hospital),
which also had the oldest patients. Only one in four surro-
gates chose All Treatment compared with nearly one in two
patients doing the same. Individuals at the academic medi-
cal center had higher burden of illness than the other two
sites as measured by the Charlson Score (median for Sites
1 and 2 = 5; Site 3 = 7). Patient primary diagnoses were
not different between surrogate and patient-signed forms
with the exception of cancers, where a larger proportion of
patient signers had cancers (26%) compared with patients
who had surrogates (11%; p < .001).
OR = 0.26; p ≤ .001; Model 3 and 4), but site-associated
effects reduced the magnitude of this effect (OR = 0.59; p ≤
.05; Model 5). Overall, patients and surrogates at the pal-
liative care sites had >90% lower odds for choosing All
Treatment than those at the LTACH (Site 2: odds ratio,
OR = 0.02 [95% confidence interval, CI, 0.01–0.05]; Site
3: OR = 0.06 [95% CI 0.02–0.10]; p ≤ .001).
A multivariable mixed effects logistic regression model,
grouped by clinicians, using all observations and the full
complement of independent variables was no different from
a model that did not cluster patients by clinician (Standard
Deviation of the Intercept = 2.58e-10 [95% CI 0.00–0.00];
Likelihood Ratio Test = 4.0e-13; p = 1.00).

Multivariable Logistic Regression
Surrogate decision makers were much less likely to choose
All Treatment than patients who made their own deci-
sions (OR = 0.34–0.46; p ≤ .001). This effect remained
unchanged as we added patient, clinician, and site char-
acteristics (Table 2; Models 1–5). Patients in the highest
age group (≥80) were consistently less likely to choose
All Treatment than those in the lowest age group (<60;
OR = 0.14–0.22; p ≤ .001; Models 2–5). Individuals with
high Charlson Scores (>5) were less likely to choose All
Treatment than those with lower Charlson Scores (<5;
Post Hoc Logistic Regression Using Only Data
from the LTACH
We tested our model post hoc using only data from the
LTACH (Site 1) to eliminate the potential for confounding
due to clinicians channeling patients into palliative care set-
tings due to prior patient or surrogate preferences to limit
life-sustaining treatments (Table 3). Using only LTACH
data, surrogate decision makers experienced 52% lower
odds for choosing All Treatment compared with patient
decision makers (OR = 0.48 [95% CI 0.28–0.84]; p = .01).
These results were substantially the same as those using

Table 2. Odds Ratios (95% Confidence Interval) for Logistic Regression Models Estimating the Odds for All Treatment versus
Limit Treatment on the Massachusetts Medical Orders for Life-Sustaining Treatment Form

N = 593 Model 1 Model 2 Model 3 Model 4 Model 5

Surrogate (vs patient 0.34*** (0.24–0.49) 0.46*** (0.31–0.67) 0.39*** (0.26–0.58) 0.36*** (0.24–0.55) 0.39*** (0.24–0.65)
signature)
Age group: (reference <60)
60–79 0.76 (0.49–1.18) 0.74 (0.47–1.16) 0.65+ (0.41–1.05) 0.41** (0.21–0.78)
80 and over 0.22*** (0.13–0.37) 0.15*** (0.09–0.26) 0.14*** (0.08–0.24) 0.19*** (0.09–0.41)
Charlson Scorea >5 0.26*** (0.17–0.39) 0.27*** (0.18–0.41) 0.59* (0.36–0.99)
(vs Charlson≤5)
Male (vs female patient) 1.71** (1.16–2.53) 1.20 (0.75–1.94)
Race/ethnicity of
patient(reference:
non-Hispanic White)
Non-Hispanic Black 2.59* (1.01–6.65) 1.37 (0.49–3.81)
 Non-Hispanic other 2.10** (1.19–3.69) 1.12 (0.59–2.12)
and Hispanic
Physician (vs NP or PA) 1.73** (1.17–2.57) 0.98 (0.59–1.63)
Site (reference site 1)
Site 2b 0.02*** (0.01–0.05)
Site 3b 0.04*** (0.02–0.10)
Pseudo-R2c 0.046++++ 0.103++++ 0.163++++ 0.195++++ 0.442++++

Notes: aScore derived from the Charlson Weighted Index of Comorbidities using discharge diagnoses (ICD-9) and does not incorporate the decade-based age
adjustment described in the original Charlson (1987) paper. bSite 1: 180-bed long-term acute care hospital with no palliative care specialist; Site 2: Palliative care
consulting practice in 300-bed community acute care teaching hospital; Site 3: Inpatient palliative care unit in 800+ bed at an academic medical center. cPseudo-R2
is an indicator of model fit and can be interpreted as the amount of variation in All versus Limit Treatment attributed to each variable.
+
p-Value of odds ratio ≤.10; *≤.05; **≤.01; ***≤.001. ++++p-Value of the model ≤.001.

Downloaded from https://academic.oup.com/gerontologist/advance-article-abstract/doi/10.1093/geront/gny042/4998924

by university of winnipeg user
on 24 May 2018
 The Gerontologist, 2018, Vol. 00, No. 00
Table 3. Post Hoc Analysis – Odds Ratios and (95%
Confidence Interval) for a Multivariable Logistic Regression
Model Estimating the Odds for All Treatmenta versus Limit
Treatment on the Massachusetts Medical Orders for Life-
Sustaining Treatment Form Using Only Site 1b Data
Odds ratio
N = 288 (95% CI) p value
Surrogate (vs patient signature) 0.48 (0.28–0.84) .010
Charlson Score >5c 0.56 (0.32–0.97) .038
Age: (reference ≤60)
60–79 0.33 (0.15–0.73) .006
80 and over 0.16 (0.07–0.40) ≤.001
Male 1.14 (0.66–1.96) .638
Race/ethnicity (reference =
non-Hispanic White)
Non-Hispanic Black 1.70 (0.54–5.33) .364
Non-Hispanic other and Hispanic 1.05 (0.53–2.07) .889
Physician (vs NP/PA signature) 1.06 (0.62–1.85) .815
Notes: aAll Treatment = “Yes” to All (resuscitate, intubate, transfer) versus
Limit Treatment = “No” to At Least One (resuscitate, intubate, transfer).
b
Site 1 is a 180-bed long-term acute care hospital with no palliative care spe-
cialist. cScore derived from the Charlson weighted Index of Comorbidities
using discharge diagnoses (ICD-9) and does not incorporate the decade-based
age adjustment described in the original Charlson (1987) paper.
data pooled for all three sites. Mixed effects multivariable
logistic regression, grouped by 31 clinicians again showed
no difference between this model and a comparable model
that did not cluster patients within clinicians (Standard
Deviation of Intercept: 1.58e-09 [95% CI 0.00–0.00];
p = 1.00).
Discussion
The goal of this study was to estimate the odds that surro-
gate decision makers would choose aggressive life-sustain-
ing treatment decisions by taking into consideration patient,
clinician, and site variables, which accounted for unmeas-
ured factors that channeled patients to each location, such
as patient insurance and patient or clinician preferences
farther upstream in the care continuum. We collected data
from the Massachusetts version of the POLST form and
corresponding patient medical records at three hospitals in
the greater Boston area. An important strength of this study
is that data represent decisions made in a health care set-
ting in the context of patients and families experiencing an
event associated with serious, life-limiting illness.
Surrogates signed 43% of the MOLST forms in our
study, which is consistent with prior results (47%; Torke
et al., 2014). Multivariable logistic regression results
showed that surrogates were 60% less likely to choose
All Treatment than patients who did not use a surrogate.
Because decisions in palliative care settings may have con-
founded the results, we performed a post hoc analysis using
only data from the LTACH, which did not have a palliative
Downloaded from https://academic.oup.com/gerontologist/advance-article-abstract/doi/10.1093/geront/gny042/4998924
by university of winnipeg user
on 24 May 2018
7
care practice. This post hoc analysis revealed essentially the
same result, that surrogate decision makers were 52% less
likely to choose All Treatment than patients not using a
surrogate.
Our results are consistent with findings using POLST
data from a nursing home population (Rahman et al., 2016),
which also used data gathered from a clinical setting. Other
studies that examined both patient and surrogate decisions
are not directly comparable because study methods were
intended to test the accuracy of surrogate decisions, and
used hypothetical scenarios (Barrio-Cantalejo et al., 2009;
Shalowitz et al., 2006), which may not reflect contextual
cues that could influence patient or surrogate decisions
when life-sustaining treatment preferences are sought in
clinical settings (Reamy, Kim, Zarit, & Whitlatch, 2011).
Surrogate decision makers face intense emotional distress
as they balance forces favoring more intervention against
those favoring less. Prior research suggest that negative cues
are most salient when surrogates need to make decisions,
such as a patient’s unconscious state or perceived pain, and
a focus on what patients do not want instead of what they
do want (Dionne-Odom, 2015).
The process of discussing end-of-life treatments with
surrogates is a delicate balance between prior patient pref-
erences and the best interests of the patient going forward
(Torke, Moloney, Siegler, Abalos, & Alexander, 2010). We
should not assume that our results reflect prior discussions
between surrogate and patient pairs, as these pairs have
shown low agreement (62%) when asked whether dis-
cussions about life-sustaining treatments had taken place
(Fried, Redding, Robbins, O’Leary, & Iannone, 2011), and
prior discussions also showed no impact on the accuracy
of substituted judgment (Pruchno, Lemay Jr., Field, &
Levinsky, 2005). Rather, our results seem to indicate that
surrogate decision makers are systematically different from
patient decision makers, which would be consistent with
prior research showing that proxy respondents represented
individuals in worse physical health, older, and were less
educated than those not using a proxy (Elliott, Beckett,
Chong, Hambarsoomians, & Hays, 2008).
Prior research about the accuracy of proxy reporting
suggests that surrogates tend to overestimate the burden
of illness, especially on subjective quality of life measures
(Ferri & Pruchno, 2009; Kirou-Mauro et al., 2006; Kutner
et al., 2006; Novella et al., 2001). This tendency can be
problematic whether clinicians guide surrogates to employ
the principle of “substituted judgment” or “best interest”
when making life-sustaining treatment decisions. Clinicians
may want to take into consideration that in some situa-
tions, surrogates may overestimate burden, such as when
life-sustaining treatment decisions are based on unobserv-
able or subjective quality of life outcomes for the patient.
Because the POLST is recommended for patients facing
their last year of life, clinicians may want to attend to com-
pleting a POLST when patients are still able to make their
own decisions and a surrogate is not yet needed.
 8 The Gerontologist, 2018, Vol. 00, No. 00
Limitations
Our study used a sample that completed MOLSTs at three
hospitals; thus, selection bias cannot be ignored. In addi-
tion to upstream forces that channeled individuals to these
hospitals, clinicians at each location selected patients for
MOLST, and patients or surrogates agreed to complete
a MOLST form. We acknowledge that our data failed
to capture patients and surrogates who were not asked
to complete a MOLST form. Some clinicians may have
been uncomfortable discussing end-of-life care goals with
patients or surrogates, whereas others may have thought
their patients would survive beyond 1 year, and still others
may have decided not to complete MOLST forms because
patients and surrogates wanted All Treatment. These biases
in the data set would likely result in odds ratios being too
low for surrogates. By the same token, patients and sur-
rogates who chose not to complete a MOLST form were
choosing All Treatment by default, and because we did
not track refusals, our estimates regarding a preference
to Limit Treatment may be high. Furthermore, we lacked
background data about patients, which would have predis-
posed them to treatment versus treatment limitations, such
as religiosity or prior declarations in advance care directive.
While we have no evidence pointing to underlying system-
atic selection bias in our sample, we also have no evidence
to support a lack of systematic selection bias.
It is reasonable to assume that clinicians and patients
in the palliative care settings were already biased against
choosing All Treatment. Patients or surrogates agreed to
treatment in these settings, and the definition of palliative
care is to treat symptoms, not disease. The post hoc analysis
using data from the LTACH, which did not have a pallia-
tive care practice, allowed us to eliminate the potential for
this bias by examining results at one location where there
was substantial variation in the dependent variable; that
is, 70% chose All Treatment. The result for the main effect
using single-site data was substantially the same as that
using the full data set, which suggests that whatever forces
led patients to the palliative care practices as opposed to
the LTACH did not change our conclusion. If anything, one
would expect that clinicians in an LTACH might approach
goals of care discussions in a manner that could bias patient
or surrogate decisions toward aggressive treatment. Again,
our single-site results do not support this direction of think-
ing; rather, they confirm that even in an aggressive treat-
ment pathway, surrogate decision makers are less likely to
choose all life-sustaining treatments than patients.
Using only one scale, the Charlson Score, to measure
severity of illness is also an important limitation in this
study. Our regression models showed that the surrogate
variable acted independently from the Charlson Score,
which suggests that the Charlson Index did not fully meas-
ure conditions that would lead to needing a surrogate deci-
sion maker, such as delirium, high fever, or nausea that
often lead to hospitalization for individuals with advanced
Downloaded from https://academic.oup.com/gerontologist/advance-article-abstract/doi/10.1093/geront/gny042/4998924
by university of winnipeg user
on 24 May 2018
illness. Further, dementia is assigned only a score of 1 on
the Charlson Index, with no further adjustment for higher
severity, even though the Index adjusts for higher severity
of cancers, diabetes, and heart disease. This limitation in the
Charlson Score, coupled with other research showing insuf-
ficient reporting or documentation of underlying dementia
in older populations (Crowther, Bennett, & Holmes, 2017;
van den Dungen et al., 2012; Ostbye, Taylor, Clipp, Van
Scoyoc, & Plassman, 2008), and a propensity for surro-
gates to favor limitations when dementia is present (Feltz
& Samayoa, 2012), indicate that future studies should
incorporate multiple measures to reflect conditions faced in
the last days or weeks of life.
Finally, our mixed effects models grouped by clinicians
did not show variation between clinicians even though
prior research point to an association between patient pref-
erences and the clinicians’ end-of-life care preferences for
themselves (Wilkinson & Truog, 2013). A larger sample
may have yielded different results. A review of the numbers
of MOLST forms completed by each of the 31 clinicians at
Site 1 showed that close to 50% completed just one or two
forms while 30% completed 11–36 forms. A larger sample,
collected over a longer period of time, would have provided
more MOLST forms for the large proportion of clinicians
who had only completed one or two forms, and may have
yielded different results.
Conclusion
The results in this study show that surrogate decision mak-
ers for a hospitalized population with serious and advanc-
ing illness were more likely to indicate a preference to limit
life-sustaining treatments than patient decision makers. In
multivariable logistic regression models, this effect operated
independently from age, practice patterns associated with
site, and the Charlson Score. Prior research demonstrating
that proxies tend to overestimate symptom burden com-
pared with patients presents a troubling ethical problem in
our results, which is whether decisions to limit treatment
by surrogates can be construed as an accurate reflection of
what the patient would have wanted. Given the frequency
with which surrogates are needed for older, hospitalized
patients, provider organizations may want to incorporate
new strategies to reach surrogates as an additional patient
decision partner. Providers may also want to consider dis-
cussing with patients and documenting their preferences
for temporary versus permanent incapacity. Finally, when
communicating with surrogate decision makers, providers
may want to keep in mind a surrogate’s tendency to overes-
timate symptom burden..
Supplementary Data
Supplementary data are available at The Gerontologist
online.
 The Gerontologist, 2018, Vol. 00, No. 00
Acknowledgments
Elizabeth E. Chen had full access to all the data in the study and
takes responsibility for the integrity of the data and the accuracy
of the data analysis. A portion of the results in this article was pre-
sented at the Gerontological Society of America Research Meeting
in New Orleans, November 2016, at the International Association
of Gerontology and Geriatrics World Congress in San Francisco,
July 2017, and via webinar hosted by the National POLST on
January 25, 2018. We gratefully acknowledge the contributions
of Mary Fairbanks, BS, who generously volunteered hundreds of
hours during the data collection phase of this study; Edward Alan
Miller, PhD, MPA, who provided important critique for earlier ver-
sions of this research; and Susan T. Moore, RN, MPH for facilitat-
ing the data collection process and providing important comments
to the final draft.
References
Al Feghali, K. A., Robbins, J. R., Mahan, M., Burmeister, C., Khan, N.
T., Rasool, N.,…Elshaikh, M. A. (2016). Predictive capacity of 3
comorbidity indices in estimating survival endpoints in women
with early-stage endometrial carcinoma. International Journal
of Gynecological Cancer: Official Journal of The International
Gynecological Cancer Society, 26, 1455–1460. doi:10.1016/j.
ygyno.2016.04.205.
American Hospital Association. (2017). Long-term care hospitals
(LTCHs). Retrieved October 22, 2017, from http://www.aha.
org/advocacy-issues/postacute/ltach/index.shtml
American Medical Association. (2016). Code of Medical Ethics
Opinions on Consent, Communications and Decision Making
Section 2.2.1. Retrieved March 3, 2018, from https://www.
ama-assn.org/sites/default/files/media-browser/code-of-medical-
ethics-chapter-2.pdf
Barrio-Cantalejo, I. M., Molina-Ruiz, A., Simón-Lorda, P., Cámara-
Medina, C., Toral López, I., del Mar Rodríguez del Aguila, M.,
& Bailón-Gómez, R. M. (2009). Advance directives and prox-
ies’ predictions about patients’ treatment preferences. Nursing
Ethics, 16, 93–109. doi:10.1177/0969733008097995
Center for Medicare and Medicaid Services. (October 2016). Long
term care hospital prospective payment system. Retrieved
October 22, 2017, from https://www.cms.gov/Outreach-and-
Education/Medicare-Learning-Network-MLN/MLNProducts/
Downloads/Long-Term-Care-Hospital-PPS-Fact-Sheet-
ICN006956.pdf
Chang, C., Yin, W., Wei, C., Wu, C., Su, Y., Yu, C., Lee, C.C., et al.
(2016). Adjusted age-adjusted Charlson Comorbidity Index
score as a risk measure of perioperative mortality before can-
cer surgery. PLoS One, 11, e0148076. doi:10.1371/journal.
pone.0148076
Charlson, M. E., Pompei, P., Ales, K. L., & MacKenzie, C. R. (1987).
A new method of classifying prognostic comorbidity in longitu-
dinal studies: Development and validation. Journal of Chronic
Diseases, 40, 373–383. doi:10.1016/0021-9681(87)90171-8
Crooks, C. J., West, J., & Card, T. R. (2015). A comparison of the
recording of comorbidity in primary and secondary care by
using the Charlson Index to predict short-term and long-term
survival in a routine linked data cohort. BMJ Open, 5, e007974.
doi:10.1136/bmjopen-2015-007974
Downloaded from https://academic.oup.com/gerontologist/advance-article-abstract/doi/10.1093/geront/gny042/4998924
by university of winnipeg user
on 24 May 2018
9
Crowther, G. J., Bennett, M. I., & Holmes, J. D. (2017). How well
are the diagnosis and symptoms of dementia recorded in older
patients admitted to hospital? Age and Ageing, 46, 112–118.
doi:10.1093/ageing/afw169
Da Silva Gane, M., Braun, A., Stott, D., Wellsted, D., & Farrington,
K. (2013). How robust is the ‘surprise question’ in predicting
short-term mortality risk in haemodialysis patients? Nephron.
Clinical Practice, 123, 185–193. doi:10.1159/000353735
Dartmouth Institute for Health Policy and Clinical Practice. (2014).
Care of chronic illness in last two years of life: Number of different
physicians seen per decedent in the last 6 months of life. Retrieved
October 22, 2017, from http://www.dartmouthatlas.org/data/
table.aspx?ind=12&loct=2&loc=2%2c3%2c4%2c5%2c6%2c7
%2c8%2c9%2c10%2c11%2c12%2c13%2c14%2c15%2c16%
2c17%2c18%2c19%2c20%2c21%2c22%2c23%2c24%2c25%
2c26%2c27%2c28%2c29%2c30%2c31%2c32%2c33%2c34%
2c35%2c36%2c37%2c38%2c39%2(TRUNCATED)
D’Hoore, W., Sicotte, C., & Tilquin, C. (1993). Risk adjust-
ment in outcome assessment: The Charlson comorbidity
index. Methods of Information in Medicine, 32, 382–387.
doi:10.1055/s-0038-1634956
Dias-Santos, D., Ferrone, C. R., Zheng, H., Lillemoe, K. D., &
Fernández-Del Castillo, C. (2015). The Charlson age comor-
bidity index predicts early mortality after surgery for pancre-
atic cancer. Surgery, 157, 881–887. doi:10.1016/j.surg.2014.
12.006
Dionne-Odom, J. N., Willis, D. G., Bakitas, M., Crandall, B., & Grace,
P. J. (2015). Conceptualizing surrogate decision making at end of
life in the intensive care unit using cognitive task analysis. Nursing
Outlook, 63, 331–340. doi:10.1016/j.outlook.2014.10.004
Drane, J. F. (1984). Competency to give an informed consent.
A model for making clinical assessments. JAMA, 252, 925–927.
doi:10.1001/jama.1984.03350070043021
van den Dungen, P., van Marwijk, H. W., van der Horst, H. E., Moll
van Charante, E. P., Macneil Vroomen, J., van de Ven, P. M.,
& van Hout, H. P. (2012). The accuracy of family physicians’
dementia diagnoses at different stages of dementia: A system-
atic review. International Journal of Geriatric Psychiatry, 27,
342–354. doi:10.1002/gps.2726
Elliott, D., Lazarus, R., Leeder, S. R. (2006). Proxy respondents relia-
bly assessed the quality of life of elective cardiac surgery patients.
Journal of Clinical Epidemiology, 59, 153–159. doi:10.1097/
DCC.0000000000000097
Elliott, M. N., Beckett, M. K., Chong, K., Hambarsoomians, K., &
Hays, R. D. (2008). How do proxy responses and proxy-assisted
responses differ from what Medicare beneficiaries might have
reported about their health care? Health Services Research, 43,
833–848. doi:10.1111/j.1475-6773.2007.00820.x
Feltz, A., & Samayoa, S. (2012). Heuristics and life-sustaining treat-
ments. Journal of Bioethical Inquiry, 9, 443–455. doi:10.1007/
s11673-012-9396-5
Ferri, C. V., & Pruchno, R. A. (2009). Quality of life in end-
stage renal disease patients: Differences in patient and
spouse perceptions. Aging & Mental Health, 13, 706–714.
doi:10.1080/13607860902845558
Fried, T. R., Redding, C. A., Robbins, M. L., O’Leary, J. R., &
Iannone, L. (2011). Agreement between older persons and their
surrogate decision-makers regarding participation in advance
 10
care planning. Journal of the American Geriatrics Society, 59,
1105–1109. doi:10.1111/j.1532-5415.2011.03412.x
Fritz, Z. B., & Barclay, S. I. (2014). Patients’ resuscitation prefer-
ences in context: Lessons from POLST. Resuscitation, 85, 444–
445. doi:10.1016/j.resuscitation.2014.01.016
Fromme, E. K., Zive, D., Schmidt, T. A., Cook, J. N., & Tolle, S. W.
(2014). Association between physician orders for life-sustain-
ing treatment for scope of treatment and in-hospital death in
Oregon. Journal of the American Geriatrics Society, 62, 1246–
1251. doi:10.1111/jgs.12889
Fromme, E. K., Zive, D., Schmidt, T. A., Olszewski, E., & Tolle, S.
W. (2012). POLST Registry do-not-resuscitate orders and other
patient treatment preferences. JAMA, 307, 34–35. doi:10.1001/
jama.2011.1956
Hammes, B. J., Rooney, B. L., Gundrum, J. D., Hickman, S. E., &
Hager, N. (2012). The POLST program: A retrospective review
of the demographics of use and outcomes in one community
where advance directives are prevalent. Journal of Palliative
Medicine, 15, 77–85. doi:10.1089/jpm.2011.0178
Harris, P. A., Taylor, R., Thielke, R., Payne, J., Gonzalez, N.,
& Conde, J. G. (2009). Research electronic data capture
(REDCap)–a metadata-driven methodology and workflow pro-
cess for providing translational research informatics support.
Journal of Biomedical Informatics, 42, 377–381. doi:10.1016/j.
jbi.2008.08.010
Hickman, S., Keevern, E., & Hammes, B. J. (2014). The effect of the
POLST (Physician Orders for Life-Sustaining Treatment) pro-
gram on clinical care: A systematic review. Journal of Palliative
Care, 30, 226–227. doi:10.1089/jpm.2008.0196
Hickman, S. E., Nelson, C. A., Moss, A. H., Hammes, B. J., Terwilliger,
A., Jackson, A., & Tolle, S. W. (2009). Use of the Physician
Orders for Life-Sustaining Treatment (POLST) paradigm pro-
gram in the hospice setting. Journal of Palliative Medicine, 12,
133–141. doi:10.1089/jpm.2008.0196
Hickman, S. E., Nelson, C. A., Moss, A. H., Tolle, S. W., Perrin,
N. A., & Hammes, B. J. (2011). The consistency between
treatments provided to nursing facility residents and orders
on the physician orders for life-sustaining treatment form.
Journal of the American Geriatrics Society, 59, 2091–2099.
doi:10.1111/j.1532-5415.2011.03656.x
Hinderer, K. A., Friedmann, E., Fins, J. J. (2015). Withdrawal
of life-sustaining treatment: patient and proxy agreement.
Dimensions of Critical Care Nursing, 34, 91–99. doi:10.1097/
DCC.0000000000000097
Institute of Medicine. (2014). Dying in America: Improving
quality and honoring individual preferences near the
end of life. Washington, DC: National Academies Press.
doi:10.17226/18748
Javier, A. D., Figueroa, R., Siew, E. D., Salat, H., Morse, J., Stewart,
T. G.,…Abdel-Kader, K. (2017). Reliability and utility of the
surprise question in CKD stages 4 to 5. American Journal of
Kidney Diseases: The Official Journal of the National Kidney
Foundation, 70, 93–101. doi:10.1053/j.ajkd.2016.11.025
Jones, J. M., McPherson, C. J., Zimmermann, C., Rodin, G., Le, L.
W., & Cohen, S. R. (2011). Assessing agreement between termi-
nally ill cancer patients’ reports of their quality of life and family
caregiver and palliative care physician proxy ratings. Journal of
Pain and Symptom Management, 42, 354–365. doi:10.1016/j.
jpainsymman.2010.11.018
Downloaded from https://academic.oup.com/gerontologist/advance-article-abstract/doi/10.1093/geront/gny042/4998924
by university of winnipeg user
on 24 May 2018
The Gerontologist, 2018, Vol. 00, No. 00
Kaesmann, L., Janssen, S., Schild, S. E., & Rades, D. (2016). Value of
comorbidity scales for predicting survival after radiochemother-
apy of small cell lung cancer. Lung, 194, 295–298. doi:10.1007/
s00408-016-9857-4
Kim, H., Ersek, M., Bradway, C., & Hickman, S. E. (2015). Physician
orders for life-sustaining treatment for nursing home residents
with dementia. Journal of the American Association of Nurse
Practitioners, 27, 606–614. doi:10.1002/2327-6924.12258
Kirou-Mauro, A., Harris, K., Sinclair, E., Selby, D., & Chow, E.
(2006). Are family proxies a valid source of information about
cancer patients’ quality of life at the end-of-life? A literature
review. Journal of Cancer Pain & Symptom Palliation, 2, 23–33.
doi:10.1300/J427v02n02_04
Kutner, J. S., Bryant, L. L., Beaty, B. L., & Fairclough, D. L.
(2006). Symptom distress and quality-of-life assessment at
the end of life: The role of proxy response. Journal of Pain
and Symptom Management, 32, 300–310. DOI:10.1016/j.
jpainsymman.2006.05.009
Li, M., Harris, I., and Lu, Z. K. (2015). Differences in proxy-reported
and patient-reported outcomes: Assessing health and functional
status among medicare beneficiaries. BMC Medical Research
Methodology, 15, 62. doi:10.1186/s12874-015-0053-7
Lorenzon, L., Costa, G., Massa, G., Frezza, B., Stella, F., & Balducci,
G. (2017). The impact of frailty syndrome and risk scores on
emergency cholecystectomy patients. Surgery Today, 47, 74–83.
doi:10.1007/s00595-016-1361-1
Massachusetts Medical Orders for Life Sustaining Treatment.
(2014). About MOLST. Accessed October 22, 2017 http://
molst-ma.org/about
Moss, A. H., Ganjoo, J., Sharma, S., Gansor, J., Senft, S., Weaner,
B.,…Schmidt, R. (2008). Utility of the “surprise” question to
identify dialysis patients with high mortality. Clinical Journal
of the American Society of Nephrology: CJASN, 3, 1379–1384.
doi:10.2215/CJN.00940208
National POLST Paradigm. (2017a). Programs in your state. Accessed
October 22, 2017 http://polst.org/programs-in-your-state/
National POLST Paradigm. (2017b). POLST & advance
directives. Accessed December 17, 2017 http://polst.org/
advance-care-planning/polst-and-advance-directives/
Novella, J. L., Jochum, C., Jolly, D., Morrone, I., Ankri, J., Bureau, F.,
& Blanchard, F. (2001). Agreement between patients’ and prox-
ies’ reports of quality of life in Alzheimer’s disease. Quality of
Life Research, 10, 443–452. doi:10.1023/A:1012522013817
Oechsle, K., Goerth, K., Bokemeyer, C., & Mehnert, A. (2013).
Symptom burden in palliative care patients: Perspectives of
patients, their family caregivers, and their attending physi-
cians. Supportive Care in Cancer, 21, 1955–1962. doi:10.1007/
s00520-013-1747-1
Ostbye, T., Taylor, D. H. Jr, Clipp, E. C., Scoyoc, L. V., &
Plassman, B. L. (2008). Identification of dementia: Agreement
among national survey data, medicare claims, and death cer-
tificates. Health Services Research, 43(1 Pt 1), 313–326.
doi:10.1111/j.1475-6773.2007.00748.x
Powell, R., Johnston, M., & Johnston, D. W. (2007). Assessing
walking limitations in stroke survivors: Are self-reports and
proxy-reports interchangeable? Rehabilitation Psychology, 52,
177–183. doi:10.1037/0090-5550.52.2.177
Pruchno, R. A., Lemay, E. P. Jr, Feild, L., & Levinsky, N. G.
(2005). Spouse as health care proxy for dialysis patients:
 The Gerontologist, 2018, Vol. 00, No. 00
Whose preferences matter? The Gerontologist, 45, 812–819.
doi:10.1093/geront/45.6.812
Rahman, A. N., Bressette, M., Gassoumis, Z. D., & Enguidanos, S.
(2016). Nursing home residents’ preferences on physician orders
for life sustaining treatment. The Gerontologist, 56, 714–722.
doi:10.1093/geront/gnv019
Reamy, A. M., Kim, K., Zarit, S. H., & Whitlatch, C. J. (2011).
Understanding discrepancy in perceptions of values: Individuals
with mild to moderate dementia and their family caregivers. The
Gerontologist, 51, 473–483. doi:10.1093/geront/gnr010
Richardson, D. K., Fromme, E., Zive, D., Fu, R., & Newgard, C. D.
(2014). Concordance of out-of-hospital and emergency depart-
ment cardiac arrest resuscitation with documented end-of-life
choices in Oregon. Annals of Emergency Medicine, 63, 375–
383. doi:10.1016/j.annemergmed.2013.09.004
Schmidt, T. A., Hickman, S. E., Tolle, S. W., & Brooks, H. S. (2004).
The physician orders for life-sustaining treatment program:
Oregon emergency medical technicians’ practical experiences
and attitudes. Journal of the American Geriatrics Society, 52,
1430–1434. doi:10.1111/j.1532-5415.2004.52403.x
Schmidt, T. A., Zive, D., Fromme, E. K., Cook, J. N., & Tolle, S.
W. (2014). Physician orders for life-sustaining treatment
(POLST): Lessons learned from analysis of the Oregon
POLST Registry. Resuscitation, 85, 480–485. doi:10.1016/j.
resuscitation.2013.11.027
Seckler, A. B., Meier, D. E., Mulvihill, M., & Paris, B. E.
(1991). Substituted judgment: How accurate are proxy
predictions? Annals of Internal Medicine, 115, 92–98.
doi:10.7326/0003-4819-115-2-92
Shalowitz, D. I., Garrett-Mayer, E., & Wendler, D. (2006). The accu-
racy of surrogate decision makers: A systematic review. Archives of
Internal Medicine, 166, 493–497. doi:10.1001/archinte.166.5.493
StataCorp. 2013. (2013). Stata statistical software release 13.1.
College Station, TX: StataCorp LP.
St-Louis, E., Iqbal, S., Feldman, L. S., Sudarshan, M., Deckelbaum,
D. L., Razek, T. S., & Khwaja, K. (2015). Using the age-adjusted
Charlson comorbidity index to predict outcomes in emergency
general surgery. The Journal of Trauma and Acute Care Surgery,
78, 318–323. doi:10.1097/TA.0000000000000457
Suhl, J., Simons, P., Reedy, T., & Garrick, T. (1994). Myth of sub-
stituted judgment. Surrogate decision making regarding life
Downloaded from https://academic.oup.com/gerontologist/advance-article-abstract/doi/10.1093/geront/gny042/4998924
by university of winnipeg user
on 24 May 2018
11
support is unreliable. Archives of Internal Medicine, 154, 90–96.
doi:10.1001/archinte.154.1.90
Tarzian, A. J., & Cheevers, N. B. (2017). Maryland’s medical orders
for life-sustaining treatment form use: Reports of a statewide
survey. Journal of Palliative Medicine, 20, 939–945. doi:10.1089/
jpm.2016.0440
Tolle, S. W., Tilden, V. P., Nelson, C. A., & Dunn, P. M. (1998). A pro-
spective study of the efficacy of the physician order form for life-
sustaining treatment. Journal of the American Geriatrics Society,
46, 1097–1102. doi:10.1111/j.1532-5415.1998.tb06647.x
Torke, A. M., Alexander, G. C., & Lantos, J. (2008). Substituted
judgment: The limitations of autonomy in surrogate decision
making. Journal of General Internal Medicine, 23, 1514–1517.
doi:10.1007/s11606-008-0688-8
Torke, A. M., Moloney, R., Siegler, M., Abalos, A., &
Alexander, G. C. (2010). Physicians’ views on the impor-
tance of patient preferences in surrogate decision-making.
Journal of the American Geriatrics Society, 58, 533–538.
doi:10.1111/j.1532-5415.2010.02720.x
Torke, A. M., Sachs, G. A., Helft, P. R., Montz, K., Hui, S. L.,
Slaven, J. E., & Callahan, C. M. (2014). Scope and out-
comes of surrogate decision making among hospitalized older
adults. JAMA Internal Medicine, 174, 370–377. doi:10.1001/
jamainternmed.2013.13315
Torke, A. M., Siegler, M., Abalos, A., Moloney, R. M., & Alexander,
G. C. (2009). Physicians’ experience with surrogate decision
making for hospitalized adults. Journal of General Internal
Medicine, 24, 1023–1028. doi:10.1007/s11606-009-1065-y
Tremblay, D., Arnsten, J. H., & Southern, W. N. (2016). A simple
and powerful risk-adjustment tool for 30-day mortality among
inpatients. Quality Management in Health Care, 25, 123–128.
doi:10.1097/QMH.0000000000000096
Vick, J., Pertsch, N., Hutchings, M., Neville, B., & Bernacki,
R. (2016). The utility of the surprise question in identify-
ing patients most at risk of death [Abstract]. Journal of
Pain and Symptom Management, 51, 342. doi:10.1016/j.
jpainsymman.2015.12.177
Wilkinson, D. J., & Truog, R. D. (2013). The luck of the draw:
Physician-related variability in end-of-life decision-making
in intensive care. Intensive Care Medicine, 39, 1128–1132.
doi:10.1007/s00134-013-2871-6