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Critical Care Medicine:
doi: 10.1097/CCM.0b013e31828a233d
Clinical Investigations

The Effect of Emotion and Physician Communication Behaviors on Surrogates’ Life-Sustaining Treatment Decisions: A Randomized Simulation Experiment*

Barnato, Amber E. MD, MPH, MS1,2; Arnold, Robert M. MD1,3,4

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Abstract

Objective:

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 decisions.

Design:

5 × 2 between-subject randomized factorial experiment.

Setting:

Web-based simulated interactive video meeting with an intensivist to discuss code status.

Subjects:

Community-based participants 35 and older who self-identified as the surrogate for a parent or spouse recruited from eight U.S. cities through public advertisements.

Interventions:

Block random assignment to emotion arousal manipulation and each of the four physician communication behaviors.

Measurements and Main Results:

Surrogate’s code status decision (cardiopulmonary resuscitation vs do not resuscitate/allow natural death). Two hundred fifty-six of 373 respondents (69%) logged-in and were randomized: 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 cardiopulmonary resuscitation. The emotion arousal manipulation increased the score on depression-dejection scale (β = 1.76 [0.58 – 2.94]) but did not influence cardiopulmonary resuscitation choice. Physician attending to emotion and framing the decision as the patient’s rather than the surrogate’s did not influence cardiopulmonary resuscitation choice. Framing no cardiopulmonary resuscitation as the norm rather than cardiopulmonary resuscitation resulted in fewer surrogates choosing cardiopulmonary resuscitation (48% vs 64%, odds ratio, 0.52 [95% CI, 0.32–0.87]), as did framing the alternative to cardiopulmonary resuscitation as “allow natural death” rather than do not resuscitate (49% vs 61%, odds ratio, 0.58 [95% CI, 0.35–0.96]).

Conclusions:

Experimentally induced emotional state did not influence code status decisions, although small changes in physician communication behaviors substantially influenced this decision.

Copyright © 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins

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