Only a quarter of hospitalised patients in large US health system had a documented surrogate decision-maker, audit finds

A retrospective cohort study used electronic health record data from 979,610 adult hospitalisation encounters (459,365 unique patients) within a large United States healthcare system between January 2020 and December 2021 to examine how often a Medical Power of Attorney (MPOA) — a legal surrogate decision-maker designation — was documented Audit/Data. Only 26.6% of encounters had documented MPOA.

Documentation varied by demographic and clinical factors: male sex and unmarried status were independently associated with higher odds of documentation, while dementia (adjusted odds ratio 1.90) and malignancy (adjusted odds ratio 2.22) were associated with higher odds, and discharge against medical advice was associated with lower odds (adjusted odds ratio 0.91). The authors conclude that low overall documentation rates represent missed opportunities to identify a decision-maker before capacity is lost, and call for targeted interventions to promote surrogate decision-maker designation, particularly in inpatient settings.

Medical Power of Attorney is a specific US legal instrument without a direct equivalent in NHS advance care planning processes such as Lasting Power of Attorney for health and welfare or the ReSPECT process; this evidence cannot be read as a measurement of UK documentation rates. What the study offers instead is a large-scale, quantified demonstration of a pattern reported elsewhere in the evidence base: that documentation of legal decision-making arrangements at the end of life is demographically uneven, and that this unevenness is measurable at scale when systems audit for it.

For services auditing their own advance care planning or Lasting Power of Attorney completion rates, this is a useful international comparator for the kind of demographic breakdown worth examining locally — sex, marital status and diagnosis-based variation — even though the specific documentation rate itself does not transfer.