Vulnerable older adults and their families face multiple challenges in medical decision making, health communication, and the emotional distress involved in facing serious illness and death. Dr. Alexia Torke's research has focused on the communication, ethical, religious and spiritual aspects of decision making for those patients who are incapacitated and require a family surrogate to make decisions for them. This K24 award will provide support for Dr. Torke's program of research and will allow her additional protected time to pursue her passion for mentoring others. The specific aims of this K24 award are to: train future aging researchers to conduct high quality research focused on decision making and outcomes for vulnerable older adults and their family members; to study the experience of family surrogate decision makers, including the impact of communication quality on decision quality and family outcomes such as anxiety, depression, and posttraumatic stress; and to measure surrogates' religious and spiritual experiences to determine whether these factors are associated with medical decision making and the medical care that patients receive at the end of life. Dr. Torke' research topic is important because nearly half of hospitalized older adults are unable to make their own medical decisions and require a family member or other surrogate to make decisions for them. Her prior research has shown that many surrogates make decisions about life and death issues under conditions of high stress and often with poor support from clinicians. Surrogates rely on various sources of emotional support and sources of value to make medical decisions, including personal, religious and spiritual beliefs. However, both surrogates and clinicians report high levels of distress due to the emotional and communication challenges of making decisions for others. Although there is evidence from patient studies that religion is associated with preferences for more aggressive care at the end of life, this has not been studied for surrogates making decisions for others. As the population ages and a greater number of older adults are at risk for cognitive impairment, the importance of surrogate decision making will only increase. Understanding the mechanisms underlying high quality decision making will allow us to best support family members and to provide the best possible care to older adults. The projects proposed in this award will leverage a database of 359 older hospitalized adults and their surrogate decision makers that Dr. Torke has developed through funding from an R01 grant from the National Institute on Aging. Additional funding from the Indiana University Health Values Grant and the Greenwall Foundation allowed Dr. Torke to also collect data on the goals of care endorsed by the surrogate, care received at the end of life, and the religious and spiritual experiences of the surrogates. Project 1 will explore the impact of communication quality on decision making...