Doctors’ Words Influence End-of-Life Decisions Made By Patients’ Families

  • Share
  • Read Later
Getty Images / Getty Images

Making the decision to approve heroic measures to save a loved one’s life can be fraught with emotion, so anxious family members tend to turn to the doctor for guidance, according to the first study to analyze the role that doctors’ language plays in end-of-life decisions.

Researchers from the University of Pittsburgh School of Medicine conducted a novel study to investigate how a doctor’s choice of words, or how his empathy and personal experience, can impact family members’ decisions to approve or not approve cardiopulmonary resuscitation (CPR) to save a critical patient’s life. They recruited 250 people with living parents or spouses in Boston, Atlanta, New York, Los Angeles, San Francisco, Dallas, Denver and Pittsburgh.

The study participants were presented with an online survey in which they were asked to imagine a hypothetical situation: one of their loved ones was in an intensive care unit with a 40% chance of dying from sepsis, a severe bacterial infection. Some of the participants were also shown pictures of their family members or loved ones on the screen to intensify the emotional impact of the experience.

(VIDEO: New CPR Guidelines: Hands Only)

The volunteers were then confronted by a doctor, played by an actor, who held a meeting with the family member online. During the simulation, the “doctor” asked the participants whether or not they wanted CPR administered to their loved one. However, the participants heard different versions of the CPR explanation.

Some of the men and women were asked whether they wanted their family member to receive CPR, which had a 10% chance of saving their loved one’s life, if the heart stopped, or if they wanted to issue a “Do Not Resuscitate” (DNR) order. About 60% opted for CPR. However, when the doctors changed the language of the DNR choice to “allow natural death,” only 49% chose CPR.

In some cases, the doctor also talked about his or her own experience and discussed what the majority of people facing similar situations generally chose. When this happened, the participants tended to go along with the majority opinion, and opt for the choice that others had taken.

(MORE: New CPR Rules: Pump First, and Save the Breaths for Later)

“Simple changes of words and perceptions about social norms resulted in large differences in CPR choices,” said study author Dr. Amber Barnato, an associate professor of clinical and translational science at the University of Pittsburgh School of Medicine in a statement. “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.”

(MORE: 9-1-1 Operators Could Save More Lives By Coaching Callers in CPR)

The fact that doctors’ words have such influence on end-of-life decisions highlights how critical the doctor-patient relationship is, and how conflicted family members feel during these difficult situations. Studies have shown that one way to ensure that such critical decisions aren’t being made under duress would be to have conversations, as difficult as they are, about what those closest to you would want early on during a long-term illness, or prior to a life-threatening health crisis. Preparing for such events can make transitioning into end-of-life care, or making emergency decisions, less stressful and less traumatic. Last May, Malene Smith Davis, CEO of Capital Caring, told TIME, “It’s all pre-planning really. People really do cope well if they have a conversation about care with their families early. When families don’t have the conversation, that’s when there’s turmoil because no one is prepared and it’s inevitable.”

Already, says Barnato, hospitals in Texas have asked their physicians to drop the DNR language from their discussions with patients and their families and to ask them whether they would prefer to “allow natural death.” There’s no denying that making these decisions can be challenging, and physicians, she says, should be aware of the role they play in influencing those difficult choices.

The study is published in the journal Critical Care Medicine.


For the Caregivers and Doctors helping patients with end-of-life-decisions there is a very helpful book called "Hard Choices for Loving People" by Hank Dunn.  I first read this book when my husband died.  I was only 37 and had not known anyone that had ever died before this book was so helpful.  I believe it has sold over 3 million copies!


As an end-of-life care provider, this is a daily challenge for us. And physicians themselves are often conflicted between doing 'everything they can' for a patient and 'allowing natural death'.  Many physicians feel that their training and expectations tell them to prevent death at all costs - even quality of life and the patient's wishes.  The other studies the article mentions, about advance care planning, are critical.  A physician can provide solid advice and wisdom about the technical advantages and disadvantages of CPR or other treatments.  But if the person has advance directives for their wishes, all the guess work and stress is relieved for the family.

Kaitlyn Henderson


Yeah, right, we doctors just aren't doing a good enough job of explaining that grandma's ribs will break under the compressions and she almost certainly won't survive having a big honkin' tube stuck down her throat and 300 joules of electricity rammed into her heart. What about the families who are collecting her Social Security check, or the son who depends on Dad to keep him employed, or the daughter who figures she can milk Mom's bank account as long as she's on life support? Families aren't always interested in doing the best for the patient, or in dealing with reality rationally and compassionately.


I am an internal medicine physician and have to have this conversation with patients and family daily. I can tell you it is one of the hardest parts of our job. It is especially hard because thanks to movies and TV shows people do not understand how amazingly harmful and ineffective CPR really is and that if you are really sick you are not coming back anywhere close to where you were before CPR. There is no way I can relay my years of experience in that short conversation. All too often the choice that is made I wouldn't wish upon my worst enemy despite all my best efforts. And yes, I have already been using the term "die naturally" rather than CPR for years now.


I have my PhD in linguistics and I can tell you that language constantly and deeply shapes our perceptions and views. It can take the same topic and completely alter the perspective "Do not resuscitate" frames the action as a negative, i.e. what will not be done. "Allow natural death" frames the choice as proactive, even a gift to the loved one. This wording would certainly help the family understand their choice as positive and with less guilt. I wish my father-in-law's doctor would have known how to word this. It would have helped my husband's family greatly.