HUMANITIES | MEDICINE AND SOCIETY The status quo bias 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 biases might play in surrogate decision- sions, referred to as “cognitive biases.” Iincapacitated patients. Several studies making regarding withdrawal of life- One cognitive bias 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 status quo bias. 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- psychology 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 One manifestation of the status quo ated with the illness rather than feel To be clear, this is not meant to suggest bias is the default effect: that decision- responsible for harm that befalls their that all surrogate disagreements with a makers will tend to stick with the default children if they make a decision to vacci- physician’s recommendation to withdraw choice even when it conflicts with their nate and the child has an adverse life-sustaining treatment can be attributed stated preferences. For example, more outcome.8 to the status quo bias, or that such deci- than one study has shown a powerful sions should always be considered irratio- default effect among participants com- Life-sustaining treatment nal. For example, the surrogate may genu- HUMANITIES pleting advance directives,4 who were The decision to consent to withdrawal of inely be carrying out the patient’s wishes more likely to select treatment options life-sustaining treatment may be influ- or acting in accordance with the patient’s consistent with the default selection than enced by the status quo bias. The deci- values and beliefs. In some cases, how- with their own expressed values. sion to withdraw is a substantial change ever, the surrogate may not have any valid What causes status quo bias? Research in the status quo and may lead the surro- reasons for disagreeing with the recom- has identified two oft-intertwined psycho- gate decision-maker to wonder, “What if mendation, or may be unable or unwilling logical phenomena as the root cause. One we had kept going? Maybe he could have to consent to withdrawal in accordance phenomenon is the influence of antici- recovered if we gave him more time. Did with the patient’s wishes or values. It is in pated regret; the status quo bias functions we make a mistake?” these cases, where the decision conflicts with the surrogate’s preferences to act in the best interests of the patient or to carry Cognitive psychology research out the patient’s wishes, and where the decision is therefore irrational, that status has uncovered a host quo bias may be the culprit. Application of psychological phenomena How can clinicians support surrogates to make good decisions on behalf of patients that cause people to make when status quo bias might influence those decisions? One approach is to pre- irrational decisions vent it from arising in the first place by turning the tables on the default effect. Clinicians can do this before life- as a regret-minimization strategy.5 If we The decision to withdraw life-sustaining sustaining treatment begins (when this is make a decision to change from the status treatment is also a clear commission; if the possible) by presenting an alternative to quo and a negative outcome results, we surrogate does nothing, the patient will the treatment as the default choice. In are more likely to imagine that things remain on life-sustaining treatment. Even cases where the physician judges life- would have been better if we had just when surrogates accept that the outcomes sustaining treatment to be nonbeneficial stuck with the status quo — and, therefore, of both maintaining life-sustaining treatment (e.g., ventilatory support for end-stage to feel regret associated with our decision. and withdrawing it are negative, the feeling pulmonary fibrosis), a comfort measures Manetti and colleagues6 refer to this as the of greater responsibility for the outcome plan could be presented as the default status quo effect — that decisions to main- associated with withdrawing life-sustaining choice. If the potential benefit is some- tain the status quo tend to be regretted treatment (the patient’s death) may moti- what uncertain, the default choice could less than decisions to change — and vate some surrogates to opt for maintaining be framed as a time-limited trial of treat- describe it as “one of the most robust phe- treatment, where they won’t feel as responsi- ment followed by withdrawal and comfort nomena in the regret literature.” ble for the outcome. Leonhardt, Keller and measures if the patient does not show The second phenomenon is the omis- Pechmann9 also suggest that the feeling signs of improvement. A time-limited trial sion bias: the greater willingness to of responsibility for negative outcomes of treatment has the advantage of setting accept harms that arise from omissions associated with one’s decisions is greater clear expectations up front and eliciting than from actions.7 Several authors have when one’s decisions have the potential to tacit agreement to withdraw treatment if suggested that the omission bias stems harm others as opposed to oneself. More- the trial fails, potentially mitigating the from a desire to avoid being the direct over, Anderson3 suggests that the per- impact of the status quo bias later on. cause of harm and the perceived greater ceived responsibility in the eyes of others When life-sustaining treatment has moral responsibility for being the cause of may also play a role in some situations; if already been started, clinicians can address that harm.3 The omission bias has been surrogates know that other people attri- the influence of the status quo bias by recog- proposed as an explanation for parental bute less responsibility and wrongdoing to nizing the signs of the omission bias, empa- hesitancy and refusal regarding vaccina- omissions, they could be biased toward thizing with surrogates who express or imply tion. These parents choose to put their omissions so they can avoid blame from concerns about withdrawing life-sustaining children at greater risk of harm associ- others for the bad outcome. treatment and then feeling responsible or to E266 CMAJ | MARCH 5, 2018 | VOLUME 190 | ISSUE 9 blame for the patient’s death. Physicians assent,” and is designed to minimize the 2. Breen CM, Abernethy AP, Abbott KH, et al. Con- flict associated with decisions to limit life- HUMANITIES can then take steps to mitigate that burden. emotional and psychological burden asso- sustaining treatment in intensive care units. J One approach is to explain to surrogates ciated with being asked to consent to with- Gen Intern Med 2001;16:283-9. that it isn’t even their decision, it is actually drawal.10 However, given that recommen- 3. Anderson CJ. The psychology of doing nothing: the patient’s decision, and their job is to be dations can influence decision-making and forms of decision avoidance result from reason and emotion.