Physician's choice of words play important role in determining critical end-of-life decisions

University of Pittsburgh Schools of the Health SciencesMay 10 2013

A physician's choice of words when talking with family members about whether or not to try cardiopulmonary resuscitation (CPR) if a critically ill patient's heart stops may influence the decision, according to a study by University of Pittsburgh researchers in the June edition of Critical Care Medicine and now available online.

"It's long been known that the way a choice is framed can influence people's decisions," noted Amber E. Barnato, M.D., M.P.H., M.S., lead author of the study and associate professor of clinical and translational science at the University of Pittsburgh School of Medicine. "Our study shows that the words physicians use may play an important role in determining critical end-of-life decisions."

For this first-of-its-kind study, Dr. Barnato and her team recruited more than 250 adult children or spouses in eight cities: Boston, Atlanta, New York, Los Angeles, San Francisco, Dallas, Denver and Pittsburgh.

The participants took part in a Web-based survey involving a hypothetical situation in which a loved one was in the intensive care unit with a 40 percent chance of dying from sepsis, a dangerous bacterial infection. Some subjects were shown a photo of their loved ones to help them imagine the situation and heighten the emotional response. An actor portrayed a physician who held a virtual, interactive meeting with the family member. The "doctor's" responses varied, using different words for the same scenarios. Additionally, some offered emotional support, and others offered only clinical information.

A key finding was that when participants were asked to choose between having their loved ones receive CPR if their hearts should stop - a treatment with a 10 percent chance of successfully reviving them - or the alternative, a "Do Not Resuscitate" (DNR) order, 60 percent chose CPR. When the alternative was described as to "allow natural death" instead of a DNR order, the number choosing CPR dropped to 49 percent.

When the actor cited "his own experience" about how most others handled such a situation, family members were more likely to choose what they believed was the common approach.

Using more empathic language did not influence CPR choice.

"Simple changes of words and perceptions about social norms resulted in large differences in CPR choices," said Dr. Barnato. "The change in terminology from 'DNR' to 'allow natural death' already has been implemented in a health system in Texas. This study suggests that the change isn't just window dressing - it makes a real difference in the choices that people make. We expect that it also may reduce feelings of guilt for choosing against CPR by making family members feel like they are doing something positive to honor their loved one's wishes at the end of life, rather than taking something away from them."