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In a survey experiment of nearly 6,000 U.S. adults, 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. Advance directives influenced recommendations, but the difference by dementia status persisted even when the directive requested treatment.
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 reported the findings in JAMA Network Open, highlighting a gap between documented wishes and the care survey participants recommended.
Participants reviewed scenarios about seriously ill, hospitalized older adults. Researchers varied whether the patient had dementia, what an advance directive said, whether a physician recommended treatment and what preferences the surrogate decision-maker held. The study measured participants’ recommendations in those hypothetical situations; it did not track treatment decisions or outcomes for actual patients.
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 figures were 38.9%, 66.3% and 14.4%.
The researchers said advance directives affected recommendations, but dementia status also mattered. The study examined several influences, including physician recommendations and surrogate preferences; the supplied report does not provide detailed numerical results for each of those factors.
Documented Wishes and Treatment Recommendations
The findings matter because surrogates may make medical decisions when a patient cannot communicate, and their judgment may not match the patient’s preferences. In the survey, a directive requesting life-sustaining treatment raised the proportion of recommendations for that care, but did not eliminate the difference between scenarios involving patients with and without dementia.
The results do not show that patients with dementia receive less treatment in clinical practice, nor do they establish why participants made different recommendations. They do suggest that assumptions about dementia could influence how people interpret a patient’s quality of life and wishes. That makes the selection and preparation of a health care decision-maker relevant to advance care planning.
The report cites prior research suggesting that more than two-thirds of older adults may face a situation in which another person has to make end-of-life medical decisions for them. That figure refers to the cited prior research, not to participants in this survey.
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How Advance Directives Entered the Survey
An advance directive records a person’s preferences for future medical care if they become unable to communicate or make decisions. A surrogate decision-maker is someone authorized or asked to make health care decisions on a patient’s behalf in that situation. The survey compared scenarios with no directive, a request for life-sustaining treatment and a request for comfort-focused care.
The study was led by Lauren Hersch Nicholas, a professor of medicine in the division of geriatric medicine at the University of Colorado Anschutz School of Medicine. The paper appeared in JAMA Network Open in 2026; its DOI is 10.1001/jamanetworkopen.2026.37691. Medical Xpress published its report on October 7, 2026.
The study’s randomized online scenarios let researchers vary details across cases and compare responses. Those responses indicate how survey participants reacted to the descriptions, but a hypothetical recommendation is not the same as a decision made in a hospital after discussion with a patient, family, clinicians and the surrogate.
“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 and University of Colorado Anschutz professor
Limits of the Survey Findings
The study measured recommendations in hypothetical scenarios, not actual care delivered to patients. The supplied report does not specify enough about the survey’s sampling and weighting to assess how closely its participants represent all U.S. adults. It also does not give detailed results for every factor varied in the experiment, such as the effect size associated with a physician’s recommendation.
The results do not establish why respondents were less likely to recommend treatment in dementia scenarios. The lead author pointed to assumptions about life with dementia as a possible influence, but the survey finding alone cannot confirm that explanation. It is also unclear from the report how recommendations might differ across types or stages of dementia, particular treatments or real clinical settings.
Keeping Care Plans Current
The study report points to ongoing conversations as a practical part of advance care planning: people can explain their values to the person they have chosen as a surrogate and revisit those discussions as health or circumstances change. It does not report a new policy, clinical guideline or follow-up study deadline.
Further research would be needed to determine whether the response patterns seen in the survey match decisions made in practice and how discussions with patients, surrogates and clinicians affect those decisions. For now, the researchers’ stated takeaway is that having a directive matters, but understanding the patient’s values may also shape how a surrogate applies it.
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, including in scenarios where an advance directive requested treatment.
How many people took part?
The study surveyed nearly 6,000 U.S. adults using an online experiment with hypothetical scenarios.
Did an advance directive affect recommendations?
Yes. For scenarios involving patients with dementia, recommendations for life-sustaining treatment were 15.6% with no directive, 41.0% when the directive requested treatment and 7.6% when it requested comfort-focused care. The study report says directives influenced recommendations, though dementia status also mattered.
Does the study show that patients with dementia receive less treatment?
No. It measured survey participants’ recommendations in hypothetical cases, not treatment delivered to actual patients. The findings do not establish what happens in hospitals or why participants responded as they did.
What do the researchers say about advance care planning?
Lead author Lauren Hersch Nicholas said planning should involve discussing a person’s values with the chosen surrogate and revisiting those conversations, rather than relying only on a written directive.
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