title: The effect of framing on surrogate optimism bias: A simulation study.
abstract: OBJECTIVE
  To explore the effect of emotion priming and physician communication behaviors on optimism bias.
  
  
  METHODS
  We conducted a 5 × 2 between-subject randomized factorial experiment using a Web-based interactive video designed to simulate a family meeting for a critically ill spouse/parent. Eligibility included age at least 35 years and self-identifying as the surrogate for a spouse/parent. The primary outcome was the surrogate's election of code status. We defined optimism bias as the surrogate's estimate of prognosis with cardiopulmonary resuscitation (CPR) > their recollection of the physician's estimate.
  
  
  RESULTS
  Of 373 respondents, 256 (69%) logged in and were randomized and 220 (86%) had nonmissing data for prognosis. Sixty-seven (30%) of 220 overall and 56 of (32%) 173 with an accurate recollection of the physician's estimate had optimism bias. Optimism bias correlated with choosing CPR (P < .001). Emotion priming (P = .397), physician attention to emotion (P = .537), and framing of CPR as the social norm (P = .884) did not affect optimism bias. Framing the decision as the patient's vs the surrogate's (25% vs 36%, P = .066) and describing the alternative to CPR as "allow natural death" instead of "do not resuscitate" (25% vs 37%, P = .035) decreased optimism bias.
  
  
  CONCLUSIONS
  Framing of CPR choice during code status conversations may influence surrogates' optimism bias.
authors.affiliation: Department of Anesthesiology, University of Virginia, Charlottesville, VA.
authors.forename: Dev
authors.initials: D
authors.lastname: Patel
authors.affiliation: Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA.
authors.forename: Elan D
authors.initials: ED
authors.lastname: Cohen
authors.affiliation: Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA; Section of Decision Sciences, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA; Department of Health Policy and Management, Pitt Public Health, University of Pittsburgh, Pittsburgh, PA. Electronic address: aeb2@pitt.edu.
authors.forename: Amber E
authors.initials: AE
authors.lastname: Barnato
mesh_terms: D000368:Aged; D016887:Cardiopulmonary Resuscitation / Q000523:psychology; D000066491:Clinical Decision-Making; D003142:Communication; D016638:Critical Illness / Q000523:psychology*; D003430:Cross-Sectional Studies; D003463:Cues; D004644:Emotions; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009769:Object Attachment; D000067656:Optimism / Q000523:psychology*; D010344:Patient Advocacy / Q000523:psychology*; D010817:Physician-Patient Relations; D010820:Physicians / Q000523:psychology; D011379:Prognosis; D016414:Resuscitation Orders
keywords: Cardiopulmonary resuscitation; Intensive care; Optimism bias; Prognosis; Surrogate decision making