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Editor's Correspondence
January 28, 2008

Physicians and Decision Making in Dementia

Arch Intern Med. 2008;168(2):241. doi:10.1001/archinternmed.2007.54

We read with interest the article by Torke et al1 on the complex issue of the physician-surrogate relationship. As geriatricians facing this problem everyday in elderly patients with advanced dementia and poor prognosis, we doubt that such a relevant matter may be left to a “guideline for physicians.” In fact, all of the 4 key issues analyzed in this article (ie, relationship building, decision-making roles, experience of the surrogate, and multiple surrogates) have borders that are too unclear. Few data support the suggested rules in a jungle of opinions, indicating attitudes that are probably “politically correct,” but the best for patients remains unclear. The surrogates mediate the patients’ choices with their own cultural background increasing the number of variables playing a role in decision making. Moreover the presence of patient's advanced directives would further increase the possible alternatives. In this complex condition, does the physician act as a neutral player or should he or she assume an autonomous role in defining a prognosis and selecting the most appropriate therapies?2