Proxy Subjective Health Status Paper MSN5270

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Proxy Subjective Health Status Paper MSN5270

Proxy Subjective Health Status

Symptom management is an important part of providing high-quality care to both children and adults. Active screening and assessment are required to identify symptoms early and institute treatment measures to optimize an individual’s health. Proxy reports, according to Roydhouse et al. (2022), are used when patients are unable to self-report.

However, in children, multiple reasons account for the use of proxy reports including an inability to speak, low cognitive ability to comprehend the complex screening tools, and acuity or severity of symptoms that make them frail (Hyslop et al., 2018). The inability to self-report necessitates a valid approach for a proxy report of children’s symptoms. Despite their increasing use in assessing and caring for children, proxy symptom reporting is based on assumptions that may potentially have ramifications, as discussed further below.

Underlying Assumptions of Proxy Subjective Health Status

In most cases, patient factors prompt the use of proxy reporting of symptoms. It is assumed that the patient, in this case, a child, is unable to speak, cannot comprehend the complexities of the screening tools or the questions asked, and is too ill to respond. Children in cancer clinics frequently meet the aforementioned criteria, necessitating the use of proxy symptom reporting.

A systematic review of 2335 articles on the use of proxy and proxy reported measures conducted by Roydhouse et al. (2022) discovered that cancer clinics made up 13% of clinical settings, bolstering the previous statement. Furthermore, it is assumed that the proxy is fully aware of the child’s illness and can legitimately account for the main complaints and history of presenting illness. This is why Mpundu-Kaambwa et al. (2022) advocate for a child’s proxy to be someone close to him or her, or someone in the immediate environment as the child, such as a parent, or guardian, or sibling. The third assumption is that the proxy’s information approximates the child’s self-report.

To evaluate the validity of a proxy version of symptoms screening in pediatric cancer patients, Hyslop et al. (2018) discovered that the proxy report of observable phenomena such as diarrhea and mouth sores had a high intraclass correlation coefficient (ICC), as did other subjective symptoms such as feeling scared or worried, disappointed, sad, or tired. This finding is reassuring because it implies that proxy reports of the stated subjective symptoms may approximate the child’s self-report.

Potential Ramifications of Having Proxy Subjective Health Status

While its use may be unavoidable in some situations, proxy symptom reporting may have ramifications. There may be a response bias, in which the information reported by the proxy differs from the information that would be reported by the patient. This type of information discrepancy may result in suboptimal patient care. The information provided by the proxy is critical in determining the extent of a disease, such as regional spread or metastatic potential in children in the cancer unit; thus, any discrepancy in the information may result in incorrect cancer staging (Murtagh et al., 2019).

Furthermore, proxy reporting may not accurately represent some of the entirely subjective symptoms. When assessing pain, for example, the patient is the most accurate person to report the severity. This, once again, may result in suboptimal care for such patients. Moreover, proxies’ omission to report symptoms may result in an incomplete diagnosis and, as a result, inadequate patient care. As much as proxy symptom reporting is used, it is important to note that the disadvantages stated may alter clinical decision-making.


The age difference could be a significant determinant of patient care. For example, children may be unable to speak or understand the questions posed, or they may be too ill to respond. As a result, someone who is aware of the child’s symptoms must account for the child’s illness history. This, however, assumes that the proxy stays close or is in the child’s immediate environment, or that the proxy can provide information that approximates the child’s self-report. While proxy symptom reporting may be unavoidable, the information discrepancy, omission of some data, and failure to provide an accurate measure of some symptoms, such as pain, may impede clinical care decisions.


Hyslop, S., Dupuis, L. L., Baggott, C., Dix, D., Gibson, P., Kuczynski, S., Johnston, D. L., Orsey, A., Portwine, C., Price, V., Spiegler, B., Tomlinson, D., Vanan, M., Tomlinson, G. A., & Sung, L. (2018). Validation of the proxy version of Symptom Screening in Pediatrics Tool in children receiving cancer treatments. Journal of Pain and Symptom Management56(1), 107–112.

Mpundu-Kaambwa, C., Bulamu, N., Lines, L., Chen, G., Dalziel, K., Devlin, N., Ratcliffe, J., & Quality of Life in Kids: Key Evidence for Decision Makers in Australia (QUOKKA) Project Team. (2022). A systematic review of international guidance for self-report and proxy completion of child-specific utility instruments. Value in Health: The Journal of the International Society for Pharmacoeconomics and Outcomes Research.

Murtagh, F. E., Ramsenthaler, C., Firth, A., Groeneveld, E. I., Lovell, N., Simon, S. T., Denzel, J., Guo, P., Bernhardt, F., Schildmann, E., van Oorschot, B., Hodiamont, F., Streitwieser, S., Higginson, I. J., & Bausewein, C. (2019). A brief, patient- and proxy-reported outcome measure in advanced illness: Validity, reliability and responsiveness of the Integrated Palliative care Outcome Scale (IPOS). Palliative Medicine33(8), 1045–1057.

Roydhouse, J. K., Cohen, M. L., Eshoj, H. R., Corsini, N., Yucel, E., Rutherford, C., Wac, K., Berrocal, A., Lanzi, A., Nowinski, C., Roberts, N., Kassianos, A. P., Sebille, V., King, M. T., Mercieca-Bebber, R., & ISOQOL Proxy Task Force and the ISOQOL Board of Directors. (2022). The use of proxies and proxy-reported measures: a report of the international society for quality-of-life research (ISOQOL) proxy task force. Quality of Life Research: An International Journal of Quality-of-Life Aspects of Treatment, Care and Rehabilitation31(2), 317–327.

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MSN5270 Theories of Nursing Reflective Analysis Paper

MSN5270 Potential Ramifications of Having Proxy Subjective Health Status Instructions

Discuss the underlying assumptions and potential ramifications of having proxy subjective health status or evaluation measures for children or those unable to speak for themselves.

Proxy Subjective Health Status or Evaluation Example 2

The quality of healthcare is acknowledged to be significantly influenced by patient experience. Delivering high-quality services thus depends on measuring and comprehending how people experience healthcare. Patient experience metrics frequently rely on self-reported information from clients (Golda et al., 2018). However, due to circumstances such as physical or mental health issues, not all patients can self-report independently.

The limitation presents a problem because such individuals\’ perspectives and experiences may differ from those who can offer input more efficiently. When patients are unable or unwilling to self-report, a proxy respondent, someone other than the patient who helps them or responds on their behalf, is frequently utilized. The paper highlights the underlying assumptions and potential ramifications of having proxy subjective health status or evaluation measures.

Proxy assumptions

Proxy responses are assumed to be a direct replacement for patient responses. As a result, proxy and patient reports have frequently merged and analyzed without considering the patient\’s information as the primary source. Establishing the degree to which replies are comparable is neglected, though it is crucial for interpreting the resulting data because proxies might not always give the same responses as patients would (Kinghorn & Afentou, 2020). The second assumption is that the proxy\’s response mirrors the patient\’s health status progression over time. There has been no consistent relationship between proxy and patient reports.

Proxy assessments of a patient\’s health status and changes in health over time have been found in several studies to be both positively or negatively biased when compared to patients\’ self-reports. Each proxy perspective can offer insightful data that may converge or deviate from patient self-assessment of Health-Related Quality of Life to varying degrees (HRQL) (Kinghorn & Afentou, 2020). The construct being assessed, the method of measurement, the proxy, the patient, and the proxy-patient relationship are some variables that impact the disparities between proxy and patient replies.

Potential ramifications

Proxy assessments may pose both positive and negative effects. Proxy assessments can augment information from self-assessments or give extra, complementary information about the patient to inform clinical decisions about patient treatment (Alvarez-Nebreda et al., 2019). Lack of complete patient evaluation information can lead to poor clinical decision-making and insufficient pain alleviation in clinical settings. On the other hand, total proxy evaluation may lead to the omission of critical data, signs, and symptoms, negatively affecting decision-making and management.

A patient\’s self-assessment ability may be limited in advanced disease or end-of-life care. Limitation occurs significantly if they have grown accustomed to pain or other symptoms, worry that potentially life-saving treatments may be discontinued, or anxious about pain management, or otherwise have a tendency to downplay the impact of these issues on their ability to function and their well-being (Alvarez-Nebreda et al., 2019).

In such cases, observations by family members of how the pain or other symptoms affect the patient\’s experience, such as sleep or social activities, may be able to supplement or provide more detailed information than the patients. For instance, parent-reported HRQL of children is taken into account when making joint decisions since parents have a significant role in determining what is best for their children and assessing the likelihood that various treatment approaches will be effective (Hyslop et al., 2018). It is crucial to consider alternate perspectives on health-related quality of life (HRQL) while making medical decisions on illnesses affecting children, such as cancer and epilepsy


Patient self-assessment of HRQL may be replaced by proxy assessments, which complement or strengthen self-assessment by eliciting the proxy\’s judgment of the patient\’s HRQL. The goal of the proxy-patient viewpoint is to elicit substituted judgment by having the proxy imagine themselves within the patient\’s body and mind as they answer the HRQL evaluation. The proxy-proxy perspective, however, allows for an assessment of HRQL in the case of children that may differ from the patient\’s own opinions without jeopardizing the validity of either construct.


Alvarez-Nebreda, M. L., Heng, M., Rosner, B., McTague, M., Javedan, H., Harris, M. B., & Weaver, M. J. (2019). Reliability of proxy-reported patient-reported outcomes measurement information system physical function and pain interference responses for elderly patients with musculoskeletal injury. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 27(4), e156-e165.

Golda, N., Beeson, S., Kohli, N., & Merrill, B. (2018). Analysis of the patient experience measure. Journal of the American Academy of Dermatology, 78(4), 645-651.

Hyslop, S., Dupuis, L. L., Baggott, C., Dix, D., Gibson, P., Kuczynski, S., … & Sung, L. (2018). Validation of the proxy version of symptom screening in pediatrics tool in children receiving cancer treatments. Journal of Pain and Symptom Management, 56(1), 107-112.

Kinghorn, P., & Afentou, N. (2020). Proxy responses to ICECAP-A: Exploring variation across multiple proxy assessments of capability well-being for the same individuals. PloS One, 15(7), e0236584.

Proxy Subjective Health Status Example 2 Discussion Response


            I agree with your summative definition of a proxy as someone who assists or responds on behalf of patients. However, it is clear from your discussion that, while a proxy may be used, the most reliable information is usually obtained from the patient. However, as you elaborate, patients’ physical or mental conditions may indeed render them unable to respond to questions, necessitating the use of a proxy respondent.

As demonstrated in the discussion, proxy symptom reporting is predicated on assumptions, one of which is that the proxy’s response is a direct replacement for the patient’s self-report and that the information the patient provides reflects the patient’s health status. Hyslop et al. (2018) found that while caring for children in the cancer unit, proxy reports of observable phenomena such as diarrhea and mouth sores, as well as other objective symptoms such as fatigue, sadness, feeling scared, and disappointment, had high intraclass correlation coefficients. This finding is encouraging because it bolsters the assumption that proxy reports may accurately reflect patients’ health status.

            Proxy reports can have both positive and negative consequences. It is clear from the discussion that a proxy’s report may augment information from the patient, informing clinical care decisions. However, the proxy’s reports may be insufficient in other situations, such as when assessing pain severity. According to Chaw et al. (2019), a proxy report on pain may underestimate the severity, resulting in suboptimal pain management.

While assessing self versus proxy-reported pain in children with cerebral palsy, Hägglund et al. (2020) found that pain was reported in 44% of those who self-reported, and in 41% of those who proxy-reported. This finding suggests that using a proxy to assess pain may result in underreporting and underestimation of pain. Clinicians are thus advised to rely on their clinical acumen and objective assessments in determining an individual’s true health status, in addition to proxy reported information.


Chaw, S., Lo, Y., Shariffuddin, I. I., Wong, J., Lee, J., Leong, D. W., Ng, K. W., & Chan, L. (2019). Evaluation of the quality of acute pain management in a pediatric surgical setting: Validation of a parent proxy modified version of the revised American Pain Society Patient Outcome Questionnaire. Paediatric Anaesthesia, 29(1), 68–76.

Hägglund, G., Burman-Rimstedt, A., Czuba, T., & Alriksson-Schmidt, A. I. (2020). Self-versus proxy-reported pain in children with cerebral palsy: A population-based registry study of 3783 children. Journal of Primary Care & Community Health, 11, 2150132720911523.

Hyslop, S., Dupuis, L. L., Baggott, C., Dix, D., Gibson, P., Kuczynski, S., Johnston, D. L., Orsey, A., Portwine, C., Price, V., Spiegler, B., Tomlinson, D., Vanan, M., Tomlinson, G. A., & Sung, L. (2018). Validation of the proxy version of Symptom Screening in Pediatrics Tool in children receiving cancer treatments. Journal of Pain and Symptom Management, 56(1), 107–112.

Proxy Subjective Health Status Example 3

The nursing middle age concepts have been applied to a few essential assertions of maintaining a proxy subjective medical status. The idea that proxies for personal health status are primarily temporal suggests that patients can understand what they perceive as healthy or a great life, or they can alter that perception. It is crucial to have a structure so that their caretakers and healthcare professionals are aware of what is troubling them because children and adults unable to talk cannot express their views on their health status (Rand and Kesselheim, 2021).

Another significant implicit premise to evaluation assessments of proxy subjective health status is that QALY (a quality-adjusted-life-year) can review estimates for children or the extent of change in children and people who cannot speak for themselves. Healthcare professionals rely upon the improvement of children\’s and non-verbal people\’s subjective proxy health status measurements. By depending on the proxy to produce an accurate answer, they utilize this to assess children\’s growth in emotional and social development.

Secondly, another supposition is that those unable to talk can self-evaluate using the HRQOL (Health-related quality of life) instrument. The patient\’s HRQOL is used as a proxy subject for youngsters and those who are unable to talk for themselves to assess the patient\’s health status. Patient self-assessment may be substituted or complemented by proxy evaluations of health-related quality of life, according to research by Germain et al. (2019).

This tool aids in evaluating the patient and their children and provides a proxy-patient perspective that is essential for the diagnosis and treatment of the patient. They assist healthcare professionals in understanding concepts impacting children to help them achieve a quality of life (Aas et al., 2020). Everyone needs a good existence devoid of pressure, depression, and adverse events, even those who cannot talk.

However, having these performance measures and proxy assessments of psychological health status for children and non-verbal individuals may have unintended consequences. Evaluating these proxies and metrics can be challenging because they are complicated. Additionally, in some cases, when the variable being assessed is the same, the assessment measures and proxies can produce erroneous results. For instance, according to Batool-Anwar et al. (2020), HRQOL cannot differentiate between real continuously positive airway pressure (CPAP) and fake CPAP. Therefore, when primarily depended upon, it may result in inaccurate evaluations of the patients, resulting in erroneous findings.


Aas, E., Silwal, S., Cyr, P. R., Holt, T., Ormhaug, S. M., & Jensen, T. K. (2020). Health-related quality of life (HRQoL) in children and adolescents with post-traumatic stress symptom: A comparison of 16D and condition-specific instruments. Nordic Journal of Health Economics, 8(1), 46-71.

Batool-Anwar, S., Omobomi, O., & Quan, S. F. (2020). The effect of CPAP on HRQOL as measured by the Quality of Well-Being Self Administered Questionaire (QWB-SA). Southwest Journal of pulmonary & critical care, 20(1), 29.

Germain, N., Aballéa, S., & Toumi, M. (2019). Measuring health-related quality of life in young children: how far have we come? Journal of Market Access & Health Policy, 7(1), 1618661.

Rand, L. Z., & Kesselheim, A. S. (2021). Controversy Over Using Quality-Adjusted Life-Years In Cost-Effectiveness Analyses: A Systematic Literature Review: Systematic literature review examines the debate over the use of quality-adjusted life-year in cost-effectiveness analyses. Health Affairs, 40(9), 1402-1410.