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A randomized survey study of nearly 6,000 U.S. adults 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 increased recommendations in both groups, but dementia status and the surrogate’s own preferences also influenced responses.
Survey participants were about 19 percentage points less likely to recommend life-sustaining treatment for a seriously ill patient with dementia than for a similar patient without dementia, even when an advance directive called for treatment, according to a University of Colorado Anschutz study published in JAMA Network Open. The findings suggest that a patient’s documented preferences may not be the only influence on decisions made by a surrogate.
The researchers surveyed nearly 6,000 U.S. adults in a randomized online experiment. Participants reviewed scenarios about seriously ill, hospitalized older adults. The researchers varied whether the patient had dementia, whether an advance directive requested life-sustaining treatment or comfort-focused care, whether there was no directive, and whether a physician recommended treatment.
For scenarios involving patients with dementia and no advance directive, participants recommended life-sustaining treatment in 15.6% of cases. That share was 41.0% when the directive requested life-sustaining treatment and 7.6% when it requested comfort-focused care. For patients without dementia, the corresponding figures were 38.9%, 66.3% and 14.4%.
The study found that directives affected recommendations in both groups, while participants were more likely to recommend treatment overall for patients without dementia. The report also says a surrogate decision-maker’s own preferences shaped responses. These figures describe recommendations made in survey scenarios; they do not measure treatment decisions in actual hospitals or establish why individual participants responded as they did.
Documented Wishes Did Not Erase the Gap
The results matter because a person who becomes too ill to communicate may depend on someone else to make medical decisions. In that situation, a written directive can state preferences, but the study indicates that a decision-maker’s views about dementia and quality of life may also affect what care they recommend. The research does not show that actual clinicians or surrogates routinely disregard directives; it identifies a difference in responses to hypothetical scenarios.
For families, the findings point to the role of communication alongside paperwork. A surrogate who understands what the patient values may be better positioned to represent those preferences, rather than relying on the surrogate’s own choices. That is the implication emphasized by the study’s lead author, not a measured outcome of the survey.
The report cites previous research suggesting that more than two-thirds of older adults may face a situation in which someone else makes end-of-life medical decisions for them. It also says many older adults have not designated a surrogate or documented preferences. The survey itself does not assess how common that situation is or test whether a particular planning approach changes care.
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How Directives Shaped Survey Responses
An advance directive records a person’s preferences for future medical care if they cannot communicate or make decisions. In the survey, the directive could request life-sustaining treatment or comfort-focused care, allowing researchers to compare recommendations across different stated wishes and dementia status.
The pattern was not that directives had no effect. Recommendations for life-sustaining treatment rose when a directive requested it and fell when it requested comfort-focused care. But the dementia-related difference remained part of the overall result: participants recommended treatment more often in scenarios about patients without dementia.
Lauren Hersch Nicholas, the study’s lead author and a professor of medicine in the University of Colorado Anschutz School of Medicine’s division of geriatric medicine, said the work examined how dementia status, directives, physician recommendations and surrogate preferences influenced responses. The study was published 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
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What the Survey Cannot Establish
The study measured responses to hypothetical scenarios, not choices made by surrogates during real medical crises. It therefore cannot establish how often dementia status changes actual care, whether a particular treatment was given against a patient’s documented wishes, or how clinicians would resolve a conflict between a directive and other considerations.
The report does not provide enough detail to determine why participants recommended treatment at different rates. Nicholas pointed to assumptions about life with dementia as a possible influence, but that explanation should not be read as a proven cause. The supplied report also does not give the full wording of the scenarios or describe the size and direction of every physician-recommendation effect.
The findings concern group-level survey patterns. They do not predict what any particular surrogate will decide, and they do not establish which treatment is appropriate for an individual patient. How well the survey results generalize to real-world decisions remains unclear from the report.
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More Conversation Around Care Preferences
The researchers’ stated next step is a broader focus on ongoing advance care planning: documenting preferences, discussing values with the person chosen as a surrogate and revisiting those conversations as health or circumstances change. Nicholas said planning should involve more than asking whether a directive exists.
The report does not announce a follow-up study, a policy change or a clinical intervention arising from these results. Further research would be needed to determine whether the patterns seen in hypothetical recommendations appear in real decisions and whether conversations between patients and surrogates alter those decisions.
For now, the published study adds evidence that stated wishes can influence recommendations without being the only factor. The real-world effect of that finding, and the extent to which better communication can close any gap between a patient’s preferences and a surrogate’s choices, remain questions for future research.
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Key Questions
What did the survey find about dementia and life-sustaining treatment?
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. The difference remained even when an advance directive requested treatment.
Did advance directives affect participants’ recommendations?
Yes. For patients with dementia, recommendations for life-sustaining treatment rose from 15.6% without a directive to 41.0% when a directive requested it. They were 7.6% when the directive requested comfort-focused care. Similar effects appeared in scenarios involving patients without dementia.
Was this research based on actual hospital treatment decisions?
No. It was a randomized online survey in which participants evaluated hypothetical scenarios. The findings describe survey recommendations, not observed care delivered in hospitals.
What did the researchers say people can take from the findings?
Lead author Lauren Hersch Nicholas said advance care planning can include documenting wishes and discussing them with the chosen surrogate. The study did not test a planning intervention or show that a specific approach changes real-world treatment.
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