A recent study looked at whether the decision-making process plays a role in the psychological morbidity associated with being a surrogate in the ICU.1

“It’s important to note how common surrogate decision-making is in this cohort of patients,” says Jesse Miller, MD, the study’s lead author and a physician at United Lung and Sleep Clinic in St. Paul, MN.

Nearly every family member interviewed could recall a decision they made on behalf of his or her loved one. Nearly half of these decisions were classified as “end-of-life” decisions, involving the patient’s “do not resuscitate” status or continuing life support.

The researchers hypothesized that family members facing end-of-life decisions would have more decisional conflict and regret than those facing non-end-of-life decisions. The small pilot study of 42 surrogates did find more decisional conflict when end-of-life decisions needed to be made. This was especially true where there was uncertainty.

“This has profound implications about how we interact with family members of our sickest ICU patients,” says Miller.

The researchers found that virtually all family members make important, often difficult, decisions, resulting in decision conflict. “It is imperative that clinicians work on improving family engagement and support in the ICU,” Miller concludes.

Ethicists can encourage clinicians to engage with families, and to incorporate family communication strategies. “These strategies include exploring patient values, listening, eliciting questions, and empathy,” says Miller.


  1. Miller JJ, Morris P, Files DC, et al. Decision conflict and regret among surrogate decision makers in the medical intensive care unit. J Crit Care 2016; 32:79-84.


  • Jesse Miller, MD, United Lung and Sleep Clinic, St. Paul, MN. Phone: (651) 726-6200. Fax: 651-726-6201. Email: jesse.miller@allina.com.