Highlights
deaths, death, infections, infectious disease
INFECTIOUS DISEASE, VIRUS, INFECTIONS
Participants completing an AD framed as an advance decision to refuse treatment were significantly less likely to choose comfort-oriented care than participants completing an AD with a neutral choice between comfort-oriented and life-prolonging care.Exposure to a COVID-19 prime had an interactive effect on documented preferences in the refusal of treatment condition, with these participants even less likely to choose comfort-oriented care.Policy makers and organizations that design templates for advance care planning, particularly in the time of the COVID-19 pandemic, should be aware how the framing of these forms can influence decisions.Evidence suggests that people who have documented their wishes for end-of-life care experience a better quality of death. Specifically, people who have completed advance decisions (ADs) are more likely to receive their preferred care and less likely to die in hospital, and there are fewer communication issues with their surrogate decision makers.While there are cultural and contextual differences between the United States and the United Kingdom that could affect decisions around end-of-life care,While the AD presents a neutral choice between comfort and life-prolonging care, UK citizens are given the option to complete an advance decision to refuse treatment (ADRT). In other words, comfort care is framed as having no treatment at all. It seems likely this framing could have an impact on how people perceive it: studies have shown that patients will accept a treatment that has no chance of improving their condition when the other option is watchful waiting—particularly when the latter is described as “doing nothing.”These decisions have not only become increasingly relevant in light of the COVID-19 pandemic but could also be influenced by exposure to news about infections, hospitalizations, and deaths. Increased mortality salience following deadly disasters has been linked to an increase in risk-seeking behavior,It seems unlikely that all but 4% of the UK population would prefer life-prolonging care, given statistics from previous studies and culturally similar countries. For example, one study found that 65% of respondents in England would choose improving the quality of their life over extending it as the priority for their treatment if they were diagnosed with a serious illness.The aim of this study is, first, to measure the effect of different form templates on decisions about end-of-life care, comparing the US AD with the UK ADRT. In the United States, standard AD forms give a free choice between prioritizing comfort or life-prolonging care. The ADRT form commonly used in the United Kingdom, however, only gives the option of comfort care for anyone completing the form. This study is the first of its kind to experimentally examine the effect of positioning comfort care as refusing treatment in the UK frame, relative to presenting the choices more neutrally in the US frame.The second aim of the study is to identify what, if any, effect priming participants to think about the COVID-19 pandemic has on these choices. The data collection was undertaken in September 2020, between the United Kingdom’s peaks of COVID-19 cases and before the first vaccines were distributed, meaning the threat of the virus was still very salient and real. Therefore, at the beginning of each form template, we add a second manipulation to include (or not) a prime with information about COVID-19.We hypothesized that most participants in all conditions would choose comfort care over life-prolonging care in line with previous research (hypothesis 1). However, we also hypothesized that participants in the UK condition would be more likely to choose life-prolonging care than participants in the US condition, due to the negative framing of comfort care as refusal of treatment (hypothesis 2). As a result of the increase in mortality salience from reflecting on the pandemic, we predicted that participants exposed to a COVID-19 prime before completing the form would be more likely to choose life-prolonging care than comfort care (hypothesis 3). Finally, we hypothesized there would be an interaction between framing and priming, with participants in the UK frame and COVID-19 prime condition even more likely to choose life-prolonging care (hypothesis 4). This is because we predicted that the UK framing of life-prolonging care as accepting treatment would be perceived as the default option, while the threat of infectious disease from the COVID-19 prime would lead to increased conformity to that norm.