Purpose: Surrogate decision makers for critically ill patients experience strong negative emotional states. Emotions influence risk perception, risk preferences, and decision making. We sought to explore the effect of emotional state and physician communication behaviors on surrogates’ life-sustaining treatment (LST) decisions.
Method: We conducted a 5x2 between-subject randomized factorial experiment, administered via the web to community-based participants 35 and older who self-identified as the surrogate for a parent or spouse. The survey involved the hypothetical situation in which their spouse or parent has been admitted to the ICU and is receiving LST and included an interactive video meeting with an intensivist. We used block random assignment to emotional priming using a photo of the surrogate’s spouse/parent versus no priming and each of 4 physician communication behaviors during the meeting (emotion handling [yes/no], framing the decision maker [patient/surrogate], framing the default [no cardiopulmonary resuscitation (CPR)/CPR], framing the alternative to CPR [allow natural death (AND)/do not resuscitate (DNR)]). The primary outcome measure was the surrogate’s code status decision (CPR vs. DNR/AND); seconary outcomes included surrogate short form profile of mood states (POMS), decisional conflict scale (DCS), confidence that the decision would be concordant with the spouse/parent's decision, and actual concordance.
Results: 256/373 (69%) respondents logged-in and were randomized. Their average age was 50, 70% were surrogates for a parent, 63.5% were women, 76% were white, 11% black, and 9% Asian, and 81% were college educated. When asked about code status, 56% chose CPR. Emotion priming increased depression-dejection (β=1.76 [0.58 – 2.94]), but did not influence CPR choice. Physician emotion handling and framing the decision as the patient’s rather than the surrogate’s did not influence CPR choice. Framing no CPR as the default rather than CPR resulted in fewer surrogates choosing CPR (48% vs. 64%, OR=0.52 [0.32-0.87]), as did framing the alternative to CPR as AND rather than DNR (49% vs. 61%, OR=0.58 [95% CI 0.35-0.96]). Surrogates who were randomized to the emotion priming condition were more confident in their code status decision if the physician used emotion handling language than if he didn’t (OR=0.45, p = 0.036). None of the experimental conditions impacted decisional conflict or concordance.
Conclusion: Experimentally-induced emotional state did not influence code status decisions, although small changes in physician communication behaviors substantially influenced this decision.