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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

doi: 10.1097/CCM.0b013e31828a233d
Clinical Investigations

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.

Supplemental Digital Content is available in the text.

1Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA.

2The CRISMA Laboratory (Clinical Research, Investigation, and Systems Modeling of Acute Illness), Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA.

3UPMC Supportive and Palliative Care Program, University of Pittsburgh Medical Center, Pittsburgh, PA.

4Institute for Doctor-Patient Communication, University of Pittsburgh, Pittsburgh, PA.

*See also p. 1814.

The work was performed at the University of Pittsburgh.

Dr. Barnato obtained funding, Drs. Barnato and Arnold contributed to study design; Dr. Barnato collected and analyzed the data and takes full responsibility for its scientific integrity; and Drs. Barnato and Arnold contributed to writing, critical review, and approval of the manuscript for submission.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (

Dr. Barnato received a research grant awarded from the National Institute of Nursing Research (K18 NR012847), with additional material support from the University of Pittsburgh Clinical and Translational Science Institute (UL1 RR024153 and UL1TR000005, Reis PI). Dr. Arnold has disclosed that he does not have any potential conflicts of interest.

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