title: Eliciting regret improves decision making at the end of life.
abstract: Management choices at the end of life are high-stake decisions fraught with emotions, chief among is regret. Our objective in this paper is to test the utility of a regret-based model to facilitate referral to hospice care while helping patients clarify their preferences on how they wish to spend the remaining days of their lives.
  
  
  
  A prospective cohort study that enrolled consecutive adult patients (n = 178) aware of the terminal nature of their disease. The patients were at the point in care where they had to decide between continuing potentially 'curative/life-prolonging' treatment (Rx) versus hospice care. Preferences were elicited using a Dual Visual Analog Scale regarding the level of regret of omission versus commission (RgO/RgC) towards hospice care and Rx. Each patient's RgO/RgC was contrasted against the predictive probability of death to suggest a management plan, which was then compared with the patient's actual choice. The probability of death was estimated using validated Palliative Performance Scale predictive model.
  
  
  
  Eighty-five percent (151/178) of patients agreed with the model's recommendations (p < 0.000001). Model predicted the actual choices for 72% (128/178) of patients (p < 0.00001). Logistic regression analysis showed that people who were initially inclined to be referred to hospice and were predicted to choose hospice over disease-directed treatment by the regret model have close to 98% probability of choosing hospice care at the end of their lives. No other factors (age, gender, race, educational status and pain level) affected their choice.
  
  
  
  Using regret to elicit choices in the end-of-life setting is both descriptively and prescriptively valid. People with terminal disease who are initially inclined to choose hospice and do not regret such a choice will select hospice care with high level of certainty.
authors.affiliation: USF Health Program for Comparative Effectiveness Research, Division for Evidence-based Medicine, Department of Internal Medicine, University of South Florida, USA; Department of Hematology, H. Lee Moffitt Cancer Center & Research Institute, USA; Department of Health Outcomes & Behavior, H. Lee Moffitt Cancer Center & Research Institute, USA; Tampa General Hospital, USA. Electronic address: bdjulbeg@health.usf.edu.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Djulbegovic
authors.affiliation: USF Health Program for Comparative Effectiveness Research, Division for Evidence-based Medicine, Department of Internal Medicine, University of South Florida, USA.
authors.forename: Athanasios
authors.initials: A
authors.lastname: Tsalatsanis
authors.affiliation: USF Health Program for Comparative Effectiveness Research, Division for Evidence-based Medicine, Department of Internal Medicine, University of South Florida, USA.
authors.forename: Rahul
authors.initials: R
authors.lastname: Mhaskar
authors.affiliation: Department of Mathematics, Indiana University, Gary, IN, 46408, USA.
authors.forename: Iztok
authors.initials: I
authors.lastname: Hozo
authors.affiliation: Department of Mathematics, Indiana University, Gary, IN, 46408, USA.
authors.forename: Branko
authors.initials: B
authors.lastname: Miladinovic
authors.affiliation: Tampa General Hospital, USA; Division of Palliative Medicine, Department of Internal Medicine, University of South Florida, USA.
authors.forename: Howard
authors.initials: H
authors.lastname: Tuch
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002755:Choice Behavior; D015331:Cohort Studies; D003657:Decision Making; D003661:Decision Support Techniques; D004644:Emotions; D005260:Female; D017051:Hospice Care; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D057240:Patient Preference; D011446:Prospective Studies; D012017:Referral and Consultation; D013727:Terminal Care; D064232:Visual Analog Scale
keywords: Decisions at end of life; Hospice referral; Regret theory