HUMANITIES | MEDICINE AND SOCIETY

The status quo and decisions to withdraw life-sustaining treatment

n Cite as: CMAJ 2018 March 5;190:E265-7. doi: 10.1503/cmaj.171005

t’s not uncommon for physicians and impasse. One factor that hasn’t been host of psychological phenomena that surrogate decision-makers to disagree studied yet is the role that cognitive cause people to make irrational deci- about life-sustaining treatment for might play in surrogate decision- sions, referred to as “cognitive biases.” Iincapacitated patients. Several studies making regarding withdrawal of life- One that is particularly show physicians perceive that nonbenefi- sustaining treatment. Understanding the worth exploring in the context of surrogate cial treatment is provided quite frequently role that these biases might play may decisions regarding life-sustaining treat- in their intensive care units. Palda and col- help improve communication between ment is the . This bias, a leagues,1 for example, found that 87% of clinicians and surrogates when these con- decision-maker’s preference for the cur- physicians believed that futile treatment flicts arise. rent state of affairs,3 has been shown to had been provided in their ICU within the influence decision-making in a wide array previous year. (The authors in this study Status quo bias of contexts. For example, it has been cited equated “futile” with “nonbeneficial,” The classic model of human decision- as a mechanism to explain patient inertia defined as a treatment “that offers no rea- making is the rational choice or “rational (why patients have difficulty changing sonable hope of recovery or improvement, actor” model, the view that human beings their behaviour to improve their health), or because the patient is permanently will choose the option that has the best low organ-donation rates, low retirement- unable to experience any benefit.”) chance of satisfying their preferences. saving rates and health plan choices in the Although there is less evidence addressing Making a decision that is inconsistent United States.3 People are psychologically the prevalence of disagreements or con- with one’s preferences is therefore con- uncomfortable with change and will stick flicts related specifically to withdrawal of sidered irrational. However, cognitive with the current state of affairs, even when life-sustaining treatment, available evi- research has uncovered a it directly conflicts with their preferences. dence shows that such disagreements are not uncommon. Breen and colleagues2 interviewed 406 physicians and nurses involved in the care of 102 patients, who reported staff–family conflict in nearly half of the patient cases. In 63% of those cases causing conflict, the most frequently cited subject of conflict was the decision to withdraw or withhold treatment; 24% of these conflicts were attributed to family members wanting to continue aggressive treatment against the recommendations of the health care team. There are myriad reasons why a surro- gate decision-maker might disagree with a physician’s recommendation to with- draw life-sustaining treatment, including religious beliefs, informational gaps and lack of trust. In some cases, however, these factors may not be present, yet sur- rogates will still disagree with a recom- mendation to withdraw treatment. This can be frustrating for clinicians, leaving them uncertain of how to resolve the Pixabay

© 2018 Joule Inc. or its licensors CMAJ | MARCH 5, 2018 | VOLUME 190 | ISSUE 9 E265 HUMANITIES as aregret-minimizationstrategy. pated regret;thestatusquobiasfunctions phenomenon is the influence of antici- logical phenomenaastherootcause.One has identified two oft-intertwined psycho with theirownexpressedvalues. consistent withthedefaultselectionthan more likelytoselecttreatmentoptions children atgreater riskofharmassoci- tion. Theseparentschooseto puttheir hesitancy and refusal regarding vaccina - proposed as an explanation for parental that harm. moral responsibility for being the cause of cause ofharmandtheperceivedgreater from adesiretoavoidbeingthedirect suggested thattheomissionbiasstems E266 than fromactions. accept harmsthatarisefromomissions sion bias:thegreaterwillingnessto nomena intheregretliterature.” describe itas“oneofthemostrobustphe- less than decisionstochange—and tain thestatusquotendtoberegretted status quoeffect—thatdecisionstomain- pleting advancedirectives, default effectamongparticipantscom- than one study has shown a powerful stated preferences.Forexample,more choice evenwhenitconflictswiththeir makers willtendtostickwiththedefault bias is the Manetti and colleagues to feelregretassociatedwithourdecision. stuck with the status quo — and, therefore, would havebeenbetterifwehadjust are morelikelytoimaginethatthings quo andanegativeoutcomeresults,we make a decision to change from the status What causes status quo bias? Research What causesstatusquobias?Research The secondphenomenonistheomis- One manifestationofthestatusquo Cognitive psychologyresearch of psychologicalphenomena that causepeopletomake 3 Theomissionbiashasbeen has uncoveredahost 7 irrational decisions Severalauthorshave 6 refer to this as the refer to this as the : that decision- 4 whowere 5 Ifwe - CMAJ over, Anderson harm othersasopposedtooneself.More- when one’sdecisionshavethepotentialto associated with one’s decisions is greater of responsibilityfornegativeoutcomes outcome. nate andthechildhasanadverse children iftheymakeadecisiontovacci- responsible forharmthatbefallstheir ated withtheillnessratherthanfeel Pechmann ble fortheoutcome.­ treatment, wheretheywon’tfeelasresponsi- vate somesurrogatestooptformaintaining treatment (thepatient’sdeath)maymoti- associated withwithdrawinglife-­ of greaterresponsibilityfortheoutcome and withdrawingitarenegative,thefeeling of bothmaintaininglife-sustainingtreatment when surrogatesacceptthattheoutcomes remain onlife-sustainingtreatment.Even surrogate does nothing, the patient will treatment is also a clear commission; if the we makeamistake?” recovered ifwegavehimmoretime.Did we hadkeptgoing?Maybehecouldhave gate decision-makertowonder,“Whatif in thestatusquoandmayleadsurro- sion towithdrawisasubstantialchange enced bythestatusquobias.Thedeci- life-sustaining treatment may be influ The decisiontoconsentwithdrawalof Life-sustaining treatment others forthebad outcome. omissions sotheycanavoidblame from omissions, theycouldbebiased toward bute lessresponsibilityandwrongdoing to surrogates knowthatotherpeople attri- may alsoplayaroleinsomesituations; if ceived responsibilityintheeyesofothers | The decision to withdraw life-sustaining The decisiontowithdrawlife-sustaining MARCH 5,2018 8 9 alsosuggestthatthefeeling 3 suggeststhattheper- Leonhardt, Keller and and Keller Leonhardt, | VOLUME 190 sustaining sustaining | ISSUE 9 - treatment and then feeling responsible or to treatment andthen feelingresponsibleorto concerns aboutwithdrawinglife-sustaining thizing withsurrogateswhoexpress orimply nizing thesignsofomissionbias, empa- the influenceofstatusquobias byrecog- already beenstarted,clinicianscan address impact ofthestatusquobiaslateron. the trialfails,potentiallymitigating tacit agreementtowithdrawtreatmentif clear expectationsupfrontandeliciting of treatmenthastheadvantagesetting signs ofimprovement.Atime-limitedtrial measures if the patient does not show ment followedbywithdrawalandcomfort be framedasatime-limitedtrialoftreat- what uncertain,thedefaultchoicecould choice. If the potential benefit is some- plan couldbepresented asthe default pulmonary fibrosis), a comfort measures (e.g., ventilatory support for end-stage sustaining treatmenttobenonbeneficial cases where the physician judges life- the treatmentasdefaultchoice.In possible) bypresentinganalternativeto sustaining treatmentbegins(whenthisis Clinicians candothisbeforelife- turning thetablesondefaulteffect. vent it from arising in the first place by those decisions? One approach is to pre when statusquobiasmightinfluence make good decisions on behalf of patients How canclinicianssupportsurrogatesto Application quo biasmaybetheculprit. decision isthereforeirrational,thatstatus out thepatient’swishes,andwhere the bestinterestsofpatientortocarry with thesurrogate’spreferencestoactin these cases, where the decision conflicts with the patient’s wishes or values. It is in to consentwithdrawalinaccordance mendation, ormaybeunableunwilling reasons fordisagreeingwiththerecom- ever, thesurrogatemaynothaveanyvalid values and beliefs. In some cases, how or actinginaccordancewiththepatient’s inely be carrying out the patient’s wishes nal. Forexample,thesurrogatemaygenu- sions shouldalwaysbeconsideredirratio- to thestatusquobias,orthatsuchdeci- life-sustaining treatment can be attributed physician’s recommendationtowithdraw that allsurrogatedisagreementswitha When life-sustainingtreatmenthas To be clear, this is not meant to suggest To beclear,thisisnotmeanttosuggest - - HUMANITIES ­

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408- - Organ Behav Hum Decis Pro Kruglanski , SM, 132: Point: the ethics of unilateral 32: A Reluctance to vaccinate: omis- - , individual differ 13. . . Keller RA. 85. I J The psychology of doing nothing: of doing nothing: The psychology 2007; Loewenstein 2013; 405- 74- Pierro 77. JM, Abernethy Fleming CJ. Burt , , , 21: SD, 94: Ritov , L Chest J Econ Psychol Baron , A 263- J CM , JR, :

I 3 2011; 2004; Breen flict associated with decisions to limit life- with decisions to limit flict associated Nicolle sustaining treatment in intensive care units. in intensive care sustaining treatment 2001;16:283-9. Gen Intern Med Anderson reason avoidance result from forms of decision 67. Psychol Bull 2003;129:139- and . Halpern directives influence Default options in advance care. how patients goals for end-of-life Aff (Millwood) induced status quo bias. Manetti Baron more after choosing a non-status-quo option? option? more after choosing a non-status-quo need for cognitive Post decisional regret under closure. ences, and normality. cess Ritov the of responsibility by seeking uncertainty: responsibility aversion and preference for indirect agency when choosing for others. chol Curtis “do not resuscitate” orders: the role of “informed assent”. sion bias and ambiguity. 1990; Leonhardt ...... This article was solicited and has been peer This article was solicited and has been peer reviewed. 2. 3. 4 5 6 7 8 10. 9

20:​ et al. ISSUE 9 ISSUE | 2005;​ RF, McLean J Crit Care KW, VOLUME 190 VOLUME | Bowman VA, - given that recommen However, 10 13. Palda “Futile” care: Do we provide it? Why? A semis- tructured, Canada-wide survey of intensive care unit doctors and nurses. 207- MARCH 5, 2018 | . dations can influence decision-making and influence decision-making dations can in the value judgments if used can mask should wrong context, recommendations they are which in situations for reserved be known wisheseither based on the patient’s a strong base of evi- or values, or there is supporting experience clinical and dence would be nonben- the view that treatment is chosen, the eficial. Whichever strategy - recogniz is issue the resolving in step first bias may be influ- ing that the status quo decision-making. encing the surrogate’s Jonathan Breslin PhD Southlake Regional Health Centre, Research & Innovation, Newmarket, Ont.; Mackenzie Health, Professional Practice, Richmond Hill, Ont. References 1 assent,” and is designed to minimize the the to minimize designed and is assent,” asso- and psychological burden emotional to with- being asked to ciated with drawal. CMAJ Another approach is to encourage a to encourage a Another approach is A third approach is for the clinician to

blame for the patient’s death. Physicians Physicians death. for the patient’s blame burden. steps to mitigate that can then take surrogates is to explain to One approach is actually even their decision, it that it isn’t job is to be decision, and their the patient’s the patient and communicatethe voice of would make.the decision the patient a spouse or lone single surrogate (e.g., decision with oth- adult child) to share the the responsibilityers, which both spreads of being blamed. Inand minimizes the risk even be suggested extreme cases, it can the deferring consider surrogates that to other familydecision-making authority they have sufficient members, provided values and knowledge of the patient’s beliefs to fulfill the role of surrogate. share responsibility for the decision with the surrogate by taking a more active role in the decision. Instead of laying out the options and asking the surrogate what he - or she wants to do, the clinician can pro vide a recommendation and then ask if the surrogate is okay with proceeding with that recommendation. This has been described by some authors as the notion of “informed