Patients with Next-of-Kin Relationships outside the Nuclear Family

Introduction

For patients who lose capacity and have no legally-appointed surrogate decision-maker, most states have laws ordering the persons who may serve as surrogate decision-makers by default.¹ A patient's spouse is usually given priority, followed by adult children, parents, and siblings. Although a growing number of adults are unmarried and live alone,² state default surrogate consent statutes vary in their recognition of important relationships beyond the nuclear family, like friends, more distant relatives, and intimate relationships outside marriage.³ Little is known, however, about how often patients identify a person who is not a nuclear family member as their next of kin.

Methods

Patients receiving care at Veterans Health Administration (VHA) facilities are asked for information about their next of kin, which is entered into the electronic record along with a description of the relationship between the patient and next of kin. We reviewed the next-of-kin relationships for patients receiving care at Connecticut VHA facilities from 2003-2013. Records were excluded if no next-of-kin relationship was listed or if the record indicated that the patient had no next of kin (for example, “has no one” or “outlived everyone”) (n=23118). We also excluded records with uninterpretable relationships (n=219) and those with evidence that the next of kin was also a legally-appointed surrogate, like a health care proxy, since legally-appointed surrogates are subject to different rules (n=1101). Next-of-kin relationships were grouped into categories.

Chi-square tests were used to compare relationships among patients under 65 and those 65 and older, with α=0.05 (two-sided). Statistical analysis was performed using SAS version 9.2 (SAS Institute, Cary, NC). The institutional review board at the VA Connecticut Health System approved the study and waived informed consent.

Results

From 2003-2013, 134241 veterans received care at Connecticut VHA facilities, of whom 109803 were included. Their mean age was 68.0 (SD 18.8) years; 93.3% were men, 87.0% were white, and 53.9% were married. For most patients (92.9%; 95% CI=92.7-93.0), the next of kin was a nuclear family member (Table). For 7761 patients (7.1%; 95% CI=7.0-7.2), a person outside the patient's nuclear family was listed. There were 3190 patients (2.9%; 95% CI=2.8-3.0) with a more distant relative and 4571 (4.2%; 95% CI=4.1-4.3) for whom the individual was not a blood or legal relative. This was most often a friend or intimate relation outside marriage, such as “baby momma,” “common law spouse,” “live in soul mate,” and “same-sex partner.” For 849 patients (0.8%; 95% CI=0.7-0.8), the relationship involved another social tie, like “landlady,” “priest,” “roommate,” or “sponsor.” Veterans under 65 were more likely than those 65 and older (9% vs. 6%; p<0.001) to have a next of kin who was not a nuclear family member.

Table.

Next-of-kin relationships for veterans in Connecticut, 2003-2013.

Relationship	All Patients (n=109,803)		< 65 years (n=39,675)		≥ 65 years (n=70,128)		p-valueb
	No.	%a (95% CI)	No.	% (95% CI)	No.	% (95% CI)
Nuclear family members	102,042	92.9 (92.7-93.0)	36,089	91.0 (90.7-91.3)	65,953	94.0 (93.8-94.2)	<.001
Spouse	53,212		14,114		39,098
Adult child	22,495		3,064		19,431
Parent	14,031		12,917		1,114
Sibling	12,304		5,994		6,310
Outside the nuclear family	7,761	7.1 (7.0-7.2)	3,586	9.2 (8.9-9.5)	4,175	6.0 (5.8-6.2)	<.001
Non-nuclear relatives	3,190	2.9 (2.8-3.0)	1,115	2.8 (2.6-3.0)	2,075	3.0 (2.9-3.1)
Niece or nephew	1,134		129		1,005
Cousin	523		195		328
Aunt or uncle	490		391		99
In-law	358		98		260
Step-parent or step-sibling	291		95		196
Grandparent	170		169		1
Grandchild	166		2		164
Other blood or legal relative	58		36		22
Other relationships	4,571	4.2 (4.1-4.3)	2,471	6.2 (6.0-6.4)	2,100	3.0 (2.9-3.1)
Friend	1,854		853		1,001
Intimate relationship outside marriage	1,329		838		491
Ex-spouse	539		252		287
Other	849		528		321

^aPercentages are percent of column totals.

^bChi-square test for differences between nuclear next-of-kin relationships and relationships outside the nuclear family for patients <65 and 65 and older.

Discussion

Among veterans in Connecticut, 7% overall – and 9% of those under 65 – had individuals listed who were not nuclear family members. State default consent statutes do not universally recognize such persons as decision-makers for incapacitated patients. Although some patients use advance directives to identify decision-makers who differ from their next of kin, completion rates remain low.⁴

Clinicians may be uncertain about whether a next of kin outside the nuclear family may make decisions for an incapacitated person, particularly the difficult choices arising with life-limiting illness. Such uncertainty may interfere with timely clinical care. In some circumstances, a guardian must be appointed – a slow and costly process.⁵

We limited our analysis to Connecticut and to veterans, who are overwhelmingly male, older than the general population, and more likely to be white and married.⁶ Additionally, patients with legally-appointed surrogates but next-of-kin relationships that did not disclose this information could not be excluded, since data about advance directives were unavailable.

A substantial number of veterans in our sample had a next of kin outside the nuclear family. If this finding is confirmed in other populations, states should consider adopting uniform default consent statutes, and these statutes should be broad and inclusive, to reflect the evolving social ties in American life.