Exploring Missing Surrogate Decision-Maker Documentation Among Older Adults Using Electronic Health Records

Yuwen Ji; Alaa Albashayreh; Stephanie Gilbertson-White

doi:10.1016/j.jpainsymman.2026.04.347

Background Surrogate decision makers (SDM) are considered the spokesperson for individuals when they lose decision-making capacity. Despite their critical importance at the end-of-life, there is a subset of patients who do not have a documented SDM. Objective To identify predictors of missing SDM documentation among older decedents using electronic health record (EHR) data. Methods EHR data from 7,360 decedents aged ≥65 years with cancer, dementia, or heart failure. Demographic factors (age, race, sex, language, religion, marital status), palliative care (PC) referrals, and ten chronic conditions were explored as potential predictors of missing SDM documentation. Descriptive statistics were calculated, and group differences between decedents with and without a documented SDM were assessed. Weighted generalized linear models with logistic regression were used to identify independent predictors. Results The mean age of the sample was 79.58 years, primarily male (56.85 %), and majority white, non-Hispanic (94.73%). Among 7,360 decedents, 326 (4.4%) lacked SDMs. For univariate comparison, religion, marital status, and PC referral were statistically different between the two groups (p < 0.05). In the fully adjusted model of the whole sample (Pseudo R²=0.21), non-English language (OR=0.23; 95% CI: 0.17,0.33), religious affiliation (OR=0.77; 95% CI: 0.68,0.86), unmarried status (OR=0.74; 95% CI: 0.66,0.82) and PC referral (OR=0.17; 95% CI: 0.15,0.19) were associated with significantly higher odds of having SDM documentation. Chronic conditions of cerebrovascular disease, dementia, kidney disease, diabetes, heart failure, and COPD were also associated with documented SDM in the model with ORs ranging from .49 to .77 with significant CIs. Conclusions Lack of documented SDMs was disproportionately found in decedents without PC involvement and few/no documented chronic conditions. The strong protective effect of non-English language warrants further investigation. These findings highlight the need for systematic screening protocols and proactive interventions to ensure SDM documentation occurs upstream, prior to acute decline at the end-of-life.

Exploring Missing Surrogate Decision-Maker Documentation Among Older Adults Using Electronic Health Records

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