A Theoretical Model of the Psychological Processes of Surrogate Decision Making at Adult End of Life in the ICU Using Cognitive Task Analysis (FR407-A)

Abstract

1.Identify and describe the psychological processes that underlie the decision making of surrogate decision makers for adults in life threatening situations in the intensive care unit.2.Identify and discuss opportunities to impact and better support surrogate decision-makers Surrogate decision makers (SDMs) take part in 1.5 million end-of-life (EOL) decisions per year. Most find the role burdensome, often do not make decisions concordant with patients’ wishes, and suffer negative psychological after effects. Strides have been made in characterizing SDMs’ outward behavior, however, little is known about the psychological processes that undergird their decision making. The aims of this study were to: 1) identify and describe the psychological processes of recent SDMs for adults at EOL in the intensive care unit (ICU), and 2) develop a theoretical model of SDMs psychological processes. Descriptive, multiple case study research design using a cognitive task analysis (CTA) interviewing approach. Nineteen SDMs completed interviews with a mean age of 59 years (± 11) who had made decisions for adult patients (mean age, 67±13 years) who died in the ICU. Data collection and analysis yielded rich descriptions of SDMs’ decision-making experiences. Analysis resulted in the PREDICAMENTS model (Psychology, Reasoning, and Ethics Demonstrated In Choices about the Acceptability of Medical Treatments and Conditions Encountered in Life Threatening Situations) of surrogate decision making, which depicts a complex and iterative web of psychological processes wherein SDMs ultimately voice acceptance or rejection of medical treatments or the patients’ conditions based on perceptions of acceptability or lack thereof towards a current or proposed medical treatment or current or forecasted patient condition. These perceptions are preceded by a number of gist impressions, moral heuristics, and negative emotions. The relationship between perceived acceptability of a medical treatment/patient condition and their verbal acts to express this verdict appears to be moderated by perceptions of family consensus. The PREDICAMENTS model exhibits significant and previously unstudied underlying psychological constructs and relationships operating in the decisionmaking of SDMs for adults at EOL.