TL;DR
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In a randomized survey of nearly 6,000 U.S. adults, participants were about 19 percentage points less likely to recommend life-sustaining treatment for a seriously ill patient with dementia than for one without dementia. Advance directives influenced recommendations, but dementia status and the surrogate’s own preferences also mattered.
A survey experiment involving nearly 6,000 U.S. adults found that participants were about 19 percentage points less likely to recommend life-sustaining treatment for a seriously ill patient with dementia than for a patient without dementia, including when an advance directive requested treatment. The University of Colorado Anschutz researchers said the findings show that a patient’s documented wishes may not be the only factor shaping recommendations by people asked to make decisions on their behalf.
The study, published in JAMA Network Open, presented participants with scenarios about seriously ill, hospitalized older adults. Researchers varied whether the patient had dementia, whether an advance directive specified life-sustaining or comfort-focused care, whether a physician recommended treatment, and the surrogate decision-maker’s preferences. The reported results show that dementia status affected recommendations even when the scenario included documented instructions.
For patients with dementia and no advance directive, participants recommended life-sustaining treatment in 15.6% of scenarios. That share was 41.0% when the directive requested life-sustaining care and 7.6% when it requested comfort-focused care. For patients without dementia, the corresponding shares were 38.9%, 66.3% and 14.4%. These are results from survey scenarios, not measurements of actual clinical decisions or patient outcomes.
The researchers also found that the surrogate’s preferences influenced recommendations. The study’s lead author, Lauren Hersch Nicholas, said the results indicate that advance directives can affect decisions, while the person making decisions can bring their own views about quality of life and treatment. The source report does not provide a detailed breakdown of how physician recommendations affected responses.
When Directives Meet Surrogate Judgment
The results matter because people with serious illness may lose the ability to communicate their preferences, leaving a designated surrogate to interpret them. The survey suggests that an advance directive may not settle every decision: recommendations also varied with the patient’s dementia status and the surrogate’s own preferences.
That finding does not establish that patients with dementia receive less treatment in hospitals, nor does it show that any particular recommendation was medically inappropriate. It does raise a practical concern for families and care planners: a document may be less useful if the chosen decision-maker does not understand the patient’s values or would substitute personal preferences for them.
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What the Survey Compared
An advance directive records a person’s preferences for future medical care if they are unable to communicate or make decisions. A surrogate is someone authorized or asked to make health care decisions for a patient who cannot do so. The experiment tested how those instructions and other scenario details shaped participants’ stated recommendations.
The source report cites previous research suggesting that more than two-thirds of older adults may face a situation in which another person needs to make end-of-life medical decisions for them. It also says many older adults have not named a surrogate or documented preferences. Those figures are background cited by the report; the new survey itself focused on responses to hypothetical cases, not on how often people have directives or how care is delivered in practice.
Nicholas, a professor in the University of Colorado Anschutz School of Medicine’s division of geriatric medicine, said the study points toward ongoing conversations as part of advance care planning. The paper appeared in JAMA Network Open in 2026, with DOI 10.1001/jamanetworkopen.2026.37691.
“People’s assumptions about what life is like with dementia appear to play an important role in how they think about treatment decisions.”
— Lauren Hersch Nicholas, study lead author and University of Colorado Anschutz professor
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Limits of the Scenario Findings
The study measured survey participants’ recommendations in hypothetical scenarios; the reported results do not show what clinicians, families or legally designated surrogates would do in real cases. It is also unclear from the source report how responses varied across participant demographics or how physician recommendations affected each result.
The reported percentage-point difference describes the overall contrast between dementia and non-dementia scenarios. The source material does not give a confidence interval or a full statistical breakdown for that comparison. The findings therefore point to a pattern in the survey but do not establish why each participant responded as they did or whether the pattern directly translates into patient care.
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More Conversations About Care Wishes
The source report does not identify a planned follow-up study or a policy change tied to the publication. The immediate next step for readers is to distinguish what the research measured from what it did not: stated recommendations in an online experiment, rather than treatment decisions recorded in hospitals.
Nicholas and her colleagues called for more ongoing advance-care-planning conversations. Their recommendation is to discuss a person’s values with the chosen surrogate, make sure that person understands the patient’s wishes, and revisit those discussions as health or circumstances change. The study does not prescribe a specific medical choice; decisions for an individual patient depend on that person’s wishes and clinical circumstances.
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Key Questions
What did the survey find?
Participants were about 19 percentage points less likely to recommend life-sustaining treatment in scenarios involving a seriously ill patient with dementia than in scenarios involving a patient without dementia. The difference remained even when an advance directive requested treatment.
Did an advance directive affect recommendations?
Yes. For dementia scenarios, participants recommended life-sustaining care in 15.6% of cases with no directive, 41.0% when a directive requested that care and 7.6% when it requested comfort-focused care. The figures reflect survey responses, not actual care delivered.
Does this show that hospitals provide less treatment to patients with dementia?
No. The study described in the report measured recommendations in hypothetical online scenarios. It did not track hospital treatment decisions or patient outcomes.
What did the researchers say families should take from the findings?
Lead author Lauren Hersch Nicholas said advance planning should include conversations with the chosen surrogate, not just completing a document. The person making decisions should understand the patient’s values and wishes.
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