Conceptualizing surrogate decision making at end of life in the intensive care unit using cognitive task analysis

Abstract

BackgroundSurrogate decision makers (SDMs) face difficult decisions at end of life (EOL) for decisionally incapacitated intensive care unit (ICU) patients. PurposeTo identify and describe the underlying psychological processes of surrogate decision making for adults at EOL in the ICU. MethodsQualitative case study design using a cognitive task analysis interviewing approach. Participants were recruited from October 2012 to June 2013 from an academic tertiary medical center's ICU located in the rural Northeastern United States. Nineteen SDMs for patients who had died in the ICU completed in-depth semistructured cognitive task analysis interviews. DiscussionThe conceptual framework formulated from data analysis reveals that three underlying, iterative, psychological dimensions (gist impressions, distressing emotions, and moral intuitions) impact an SDM's judgment about the acceptability of either the patient's medical treatments or his or her condition. ConclusionThe framework offers initial insights about the underlying psychological processes of surrogate decision making and may facilitate enhanced decision support for SDMs.