Surrogate decision-making during hospital care transitions for persons with dementia: role of palliative care

Persons with dementia (PWD) are frequently hospitalized and often require surrogate decision-making during care transitions. Their caregivers commonly report uncertainty, limited information, and lack of support. Although palliative care improves communication, less is known about how it supports surrogate decision-making during hospital care transitions. In this qualitative study, we examined caregivers’ experiences of surrogate decision-making for hospitalized PWD who receive palliative care consultations. Semi-structured interviews were conducted with 18 family caregivers and examined with thematic analysis guided by the Ottawa Decision Support Framework. Three interrelated themes emerged. First, decisional uncertainty was driven by limited prognostic guidance, inconsistent information, and clinical instability, which included fluctuating cognition and function. Second, palliative care consultations supported decision-making through a relational process of clear communication, prognostic guidance, and support for reflecting on patient values and goals. Third, structural barriers - insurance constraints, limited service availability, and communication gaps - limited caregivers’ ability to implement care decisions even when goals had been clarified. Surrogate decision-making for PWD during hospitalization is shaped by informational, relational, and structural factors. Palliative care supports decision-making not only by improving knowledge but also by facilitating ongoing dialogue that helps caregivers interpret clinical situations and clarify goals. Improving decision quality alone is insufficient without addressing system-level barriers that affect care transitions. Not applicable.