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A randomized survey experiment found 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 requesting treatment raised recommendations in both groups, but did not eliminate the difference. The study measured survey responses, not actual clinical decisions or patient outcomes.
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, even when the patient’s advance directive requested treatment. The University of Colorado Anschutz researchers said the results suggest a documented preference can influence surrogate recommendations without fully removing the effect of dementia status.
Published in JAMA Network Open, the study asked participants to review scenarios about seriously ill, hospitalized older adults. Researchers varied whether a patient had dementia, whether an advance directive requested life-sustaining or comfort-focused care, whether a physician recommended treatment, and what the surrogate decision-maker preferred. The experiment measured participants’ recommendations in hypothetical situations; it did not track treatment decisions in hospitals.
For patients with dementia and no advance directive, participants recommended life-sustaining treatment in 15.6% of scenarios. That share rose to 41.0% when the directive requested life-sustaining treatment and fell to 7.6% when it requested comfort-focused care. For patients without dementia, the corresponding rates were 38.9%, 66.3% and 14.4%.
The researchers reported that the pattern was similar across dementia and non-dementia scenarios: directives asking for treatment increased recommendations, while directives favoring comfort-focused care reduced them. Participants were still more likely to recommend life-sustaining care for patients without dementia. The study also found that surrogate preferences mattered, though the supplied report does not provide numerical estimates for that factor.
Why Dementia Status Changed Recommendations
The results matter because a person who cannot communicate may depend on a surrogate to interpret or carry out their care preferences. The study suggests that assumptions about life with dementia may shape those recommendations, potentially alongside written instructions. It does not establish that patients with dementia receive less treatment in clinical practice, but it identifies a possible tension between a person’s documented wishes and another person’s judgment about what care is appropriate.
Lead author Lauren Hersch Nicholas said the gap matters because a patient’s wishes may not be reflected in care if the decision-maker has a different view of quality of life. The findings also indicate that advance directives can affect recommendations while leaving other influences in place. For readers planning future care, the study’s authors emphasize discussing personal values with a chosen decision-maker, rather than relying on a document alone. These are implications drawn by the researchers, not evidence that any specific planning approach guarantees a particular medical outcome.
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What the Survey Tested
An advance directive records a person’s preferences for future medical care if they become unable to communicate or make decisions. A surrogate is someone authorized or selected to make health care decisions when a patient cannot do so. In the survey, the researchers varied directive wording and other features of hypothetical cases to examine how each affected participants’ recommendations.
The study’s publication details identify it as a 2026 paper in JAMA Network Open, with DOI 10.1001/jamanetworkopen.2026.37691. The Medical Xpress report, published October 7, described the results and quoted Nicholas, a professor of medicine in geriatric medicine at the University of Colorado Anschutz School of Medicine. The supplied report also cites prior research suggesting that more than two-thirds of older adults may face a situation in which another person makes end-of-life medical decisions for them; it does not give the methods or full citation for that estimate.
“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
Limits of the Survey Evidence
The study used hypothetical scenarios, so it remains unclear whether the same differences occur in actual clinical decisions or change what treatment patients receive. The supplied report does not detail the survey’s participant demographics, the exact wording of every scenario, the size of the effect attributed specifically to physician recommendations, or how participants’ responses varied by relationship to the hypothetical patient.
The reported 19-percentage-point difference is presented as an overall comparison, while the scenario-specific rates show variation by directive status. The report does not provide confidence intervals or other statistical detail in the material supplied here. The findings also do not explain why participants responded differently; the authors’ comments about assumptions and quality of life are interpretations, not a direct measure of participants’ reasoning.
Researchers Call for Continued Planning
Nicholas and her colleagues call for more and better conversations about end-of-life care, including whether a directive still reflects a person’s wishes and whether the selected surrogate understands those wishes. Their recommendation is for ongoing advance care planning as health and circumstances change, rather than treating the completion of a form as the end of the process.
The supplied report does not announce a follow-up study, policy change or clinical guideline based on these results. Further research would be needed to test whether the survey pattern appears in real-world care and to identify which factors most influence surrogate decisions. For now, the confirmed development is a survey finding about recommendations—not evidence of a measured change in treatment delivered to patients.
Key Questions
What did the survey find?
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, according to the study report.
Did an advance directive affect recommendations?
Yes. For hypothetical patients with dementia, recommendations for life-sustaining treatment rose from 15.6% without a directive to 41.0% when a directive requested treatment. A comfort-focused directive was associated with a 7.6% recommendation rate.
Does the study show that patients with dementia receive less care?
No. It measured survey participants’ responses to hypothetical scenarios, not treatment delivered in hospitals or patient outcomes.
What did the researchers say people should take from the findings?
Lead author Lauren Hersch Nicholas said advance care planning should include conversations with the chosen surrogate about a patient’s values, and those discussions should be revisited as circumstances change.
Source: rss
