title: The Language of End-of-Life Decision Making: A Simulation Study.
abstract: BACKGROUND
  Framing is known to influence decision making.
  
  
  OBJECTIVE
  The study objective was to describe language used by physicians when discussing treatment options with a critically and terminally ill elder.
  
  
  METHODS
  High-fidelity simulation was used, involving an elder with end-stage cancer and life-threatening hypoxia, followed by a debriefing interview. Subjects were hospitalist, emergency medicine, and critical care physicians from three academic medical centers. Measures were observation of encounters in real time followed by content analysis of simulation and debriefing interview transcripts. During the simulation we identified the first mention ("broaching") of principal treatment options--intubation and mechanical ventilation (life-sustaining treatment [LST]) and palliation in anticipation of death (palliation)--and used constant comparative methods to identify language used. We identified physician opinions about the use of LST in this clinical context during the debriefing interviews, and compared language used with opinions.
  
  
  RESULTS
  Among 114 physician subjects, 106 discussed LST, 86 discussed palliation, and 84 discussed both. We identified five frames: will (decided), must (necessary), should (convention), could (option), and ask (elicitation of preferences). Physicians broached LST differently than palliation (p<0.01), most commonly framing LST as necessary (53%), while framing palliation as optional (49%). Among physicians who framed LST as imperative (will or must), 16 (30%) felt intubation would be inappropriate in this clinical situation.
  
  
  CONCLUSIONS
  In this high-fidelity simulation experiment involving a critically and terminally ill elder, the majority of physicians framed the available options in ways implying LST was the expected or preferred choice. Framing of treatment options could influence ultimate treatment decisions.
authors.affiliation: 1 Department of Pediatrics and Communicable Diseases, University of Michigan , Ann Arbor, Michigan.
authors.forename: Annie
authors.initials: A
authors.lastname: Lu
authors.affiliation: 2 Department of Critical Care Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania.
authors.forename: Deepika
authors.initials: D
authors.lastname: Mohan
authors.affiliation: 3 Department of Consumer Science, Purdue University , West Lafayette, Indiana.
authors.forename: Stewart C
authors.initials: SC
authors.lastname: Alexander
authors.affiliation: 4 Department of Medicine, Division of Hematology, Oncology, and Transplantation, University of Minnesota , Minneapolis, Minnesota.
authors.forename: Craig
authors.initials: C
authors.lastname: Mescher
authors.affiliation: 5 Section of Decision Sciences, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania.|6 Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh , Pittsburgh, Pennsylvania.
authors.forename: Amber E
authors.initials: AE
authors.lastname: Barnato
mesh_terms: D000046:Academic Medical Centers; D000368:Aged; D001291:Attitude of Health Personnel; D003142:Communication; D003422:Critical Care; D003657:Decision Making; D004635:Emergency Medicine; D020445:Hospitalists; D006801:Humans; D007407:Interviews as Topic; D010166:Palliative Care; D016544:Patient Simulation; D010817:Physician-Patient Relations; D010818:Practice Patterns, Physicians'; D013727:Terminal Care