1. Introduction
Each year, 8.2 million people worldwide die of cancer; most (70%) of these cancer deaths occur in Asia [
1]. Cancer patients often require transfer to intensive care units (ICUs) after they undergo invasive procedures such as cardiopulmonary resuscitation and tracheotomy or when they suffer comorbidities such as acute respiratory failure, infection induced by disease progression or treatment, cardiovascular disorders, and neurological disorders [
2,
3]. The patient or the surrogate (if the patient lacks clear consciousness) may inform the medical team that palliative care is acceptable. After signing a statement in accordance with the Hospice Palliative Care Act, the patient is transferred to a hospice ward or a palliative care ward according to the condition of the patient. Policies for ICU visits differ by country and by institution. In Taiwan, for example, most ICUs limit visits to 30 min two times a day and by no more than two visitors at a time. The rationale is to protect the privacy of the patients, control infection, and minimize interference with treatment. In comparison, visitor policies are relatively more flexible in the United States but relatively stricter in the UK and elsewhere in Western Europe [
4].
For cancer patients who lack capacity to make decisions about their medical care while in ICU, healthcare decisions are often made by a surrogate or relatives. Nearly 95% of cancer patients cannot make their own medical decisions at the time of ICU admission and must rely on a surrogate [
5]. In Taiwan, a patient under clear consciousness can sign a letter of appointment for a pre-determined surrogate. A surrogate is defined as a family member, friend, or other person who communicates the preferences of the patient regarding medical treatment and makes major medical decisions for the patient, such as consenting to life-sustaining treatments, end-of-life care, etc. Decision-making abilities include the abilities to understand and clearly express ideas, to make decisions about treatment, and to evaluate and debate the merits of available treatment options [
6]. In Taiwan, a surrogate must be aged 20 years or older and have behavioral capacity to make healthcare-related decisions on behalf of the patient. Legally, surrogates appointed by medical institutions have the right to make medical decisions for the patient, even if family members disagree. If a patient has not signed a letter of appointment for a pre-determined surrogate, healthcare-related decisions can be made by a legal relative [
7,
8,
9].
An ICU admission is a crisis situation for both the patient and the surrogate. For example, 14–81% of the family members of ICU patients have symptoms of posttraumatic stress disorder after they participate in making healthcare decisions for the patient [
5]. In a study of stress experienced by family members of ICU patients treated at a Taiwan medical center, Li (2017) found that stress in family members peaked within 48 h after the ICU transfer [
10]. Contributing factors include the unfamiliar environment of the ICU, fatigue, negative emotions (e.g., hopelessness, anxiety, and fear), and limited understanding of the knowledge aspects of the treatment. This stress can cause strain in family relationships or friendships, disputes over medical decisions, and poor healthcare-related decisions by surrogates. Additionally, some populations of patients (e.g., elders living alone, unmarried people, and sexual and gender minorities) may not have a strong personal affinity with their legal surrogates. Surrogates for these populations may endure inner conflict during decision-making and during efforts to reach a family consensus. The combination of a complex medical condition and a complex family relationship further increases the possibility of decision-making conflicts.
The decision-making process in ICU surrogates may differ by culture, and culture directly affects individual behaviors. For example, social harmony is the essence of Confucian theories of social interaction in Chinese culture. Chinese society is relational and collective. The social interactions and behaviors of all members of society are guided by Confucian social norms, which make social interaction more complex compared to that in western culture [
11,
12]. All relationships in a Confucian society can be classified into five types: superior and subordinate, father and son, husband and wife, elder brother and younger, and friends. Each person in a social relationship has a personal responsibility to maintain the relationship. Social goals also represent different types and levels of love. According to the theory of love proposed by the social psychologist Zick Rubin in 1970, love is the deepest and most meaningful of sentiments. Love is also a multifaceted attitude that a person has about another [
13]. Since love is an abstract concept, however, the definition of love depends on the perspective of the individual. That is, the definition of love differs because individual feelings, behaviors, and attitudes differ [
14]. Another theory of love is the Sternberg “triangular” theory. According to Sternberg, love has three components: intimacy, passion, and decision/commitment. Each type of love can occur in an interactive and dynamic intimate relationship. In western culture, contact between two people, including physical contact and even eye contact, indicates a strong relationship (deep love) [
13,
14]. Different types of love are also recognized in Chinese culture. With the exception of friendships, all five of the Confucian relationships are vertical relationships, e.g., “respect” versus “humble” and “up” versus “down”. Therefore, in Chinese culture, emotions are expressed in a roundabout and restrained manner in all relationships except friendships.
Because of their love, ICU surrogates worry about losing patients. The roles and relationships of family members also change when they must make healthcare decisions that could determine whether or not the patient survives. In this situation, families experience anxiety and other negative emotions [
15]. Research indicates that 20–46% of cancer patients meet the clinical criteria for depression and worry, and up to 75% of spouses experience negative emotions [
10]. Chinese populations often have a sense of responsibility and obligation to the family or social group. That is, family and social relationships are prioritized, unlike Western culture, in which the independence of the individual and the freedom to make choices are valued and prioritized [
11,
12]. Therefore, family and social relationships and attempts to integrate with the family or a social group can cause psychological distress.
Cultural attitudes about medical decision-making may be different. For example, Dionne-Odom et al. (2015) investigated decision-making experiences in 19 primary surrogate decision-makers of patients in critical care units in the rural Northeastern United States. In these surrogates, decision-making was impacted by gist impressions, distressing emotions, and moral intuitions [
16]. In another study in the United States, Moss et al. (2019) interviewed seven surrogates (four Caucasian and three African American) and deduced three major themes of the decision-making process: “communication as key in decision making”, “impact of past experiences”, and “difficulties and coping” [
17]. Asians traditionally have low completion rates for advance care planning (ACP) and tend to rely on the family model of medical decision-making. Su et al. (2014) investigated the decision-making experience in 69 medical care surrogates (29% African American, 26% White, 26% Asian/Pacific Islander, and 19% Latino) and identified six subthemes, including two Communication subthemes (unspoken expectations and discussion of death as taboo), two Emotion subthemes (emotional stress and feelings of loneliness), and two Conflict subthemes (family conflict and potential solutions for preventing conflict) [
18]. These studies indicate that cultural attitudes about medical decision-making and filial expectations may cause some surrogates to experience stress and family conflict.
Until now, most studies of surrogate decision-making for cancer patients in ICUs have been performed in western countries. Seldom studies have considered how surrogate decision-making is affected by cultural aspects unique to Asian populations such as the reluctance to discuss the impending death of a family member, which is considered taboo in Chinese culture. Even surrogates who recognize that discussion with other family members would improve the decision-making process for loved ones with cancer may avoid discussing these matters until a poor outcome occurs, e.g., coma or sudden death. Although ICU medical teams routinely assist surrogates in making medical decisions, the decision-making process in surrogates of cancer patients in ICU are not well understood. One study explored the quality of care delivered to ICU patients at the end stage showing end-of-life signs and symptoms. The authors reported that, although ICU personnel can determine whether or not death is inevitable, the ICU environment limits opportunities for surrogates to communicate with healthcare professionals. Lack of advance care planning (ACP) or lack of other documentation that expresses the will of the patient (e.g., do-not-resuscitate order) places the decision-making burden on the surrogate. Surrogates have insufficient time to bear the decision related to patient’s bad outcome, leading to poor quality in the face of patient’s death for surrogates confusing [
19].
In Taiwan, ACP has not yet matured. The Hospice Palliative Care Act can only be signed for patients with terminal cancer, and the Patient Right to Autonomy Act was only recently passed in 2019 [
6]. However, ACP has limitations. First, most patients in critical care units in Taiwan are highly reliant on their surrogates. For patients with complex clinical conditions, accurately predicting the outcomes of a medical treatment is often difficult. The preferred treatments indicated by patients during the ACP process may later prove impractical or inapplicable. Additionally, patients may not anticipate various outcomes when they indicate their preference for active treatment. For example, during ACP, the active treatment that a patient selects for progression of cancer may not be appropriate if the patient also has pneumonia. Preferences for active treatment indicated in ACP may not be a good choice for the patient and may later present a dilemma for the surrogate. For patients who do not sign an ACP or who do not sign a “do-not-resuscitate“ order, family members, especially in Asia, may prefer that the patient continue to live for reasons such as their strong emotional bond with the patient, pending property issues, etc., even if it is not in the best interest of the patient. Although longevity is considered a blessing in Confucian society, family harmony is equally important in Asia. Regardless of their current relationship, all family members desire harmony and may make a decision inconsistent with the preferences of the patient. Differences in family relationship, filial piety, etc. result in a decision-making experience very different from that in western culture [
20]. Studies of medical decision-making for acute care patients or for children have elucidated the highly complex and multifaceted process of surrogate decision-making. However, little is known about the experience, the feelings, and the needs of surrogates of cancer patients in ICUs in Asia. Therefore, the objective of this study was to explore the experience of surrogates of cancer patients in ICU during the medical decision-making process.
4. Discussion
Figure 1 is the qualitative model of the decision-making process of surrogates in this study. Decision-making by a surrogate was affected by love for the patient and the close personal relationship with the patient. Four effects of this close relationship were identified: (1) Use love to resist: internal angst; (2) Allow an angel to spread love among us: memories and emotional entanglements; (3) Dilemmas of love: anxiety about ICU visitor restrictions; and (4) Suffocating love: entanglement in decision-making.
The surrogates in this study reflexively blamed themselves and hoped to reduce or compensate for the pain and suffering experienced by the patient. In some cases, the feeling of reluctance to make decisions further evolved into self-blame and then feelings of internal angst, which they described as a heartbreaking situation. Research shows that approximately 30% of surrogates experience anxiety and depression when a family member is in ICU, but the anxiety and depression taper off during the ICU stay [
27]. Surrogates in this study experienced inner conflict and hesitance when they were required to make decisions that would result in physical disfigurement of the patient. The surrogates in this study also perceived that limited visiting hours weakened their emotional bonds with the ICU patients. Limited contact with patients induced mental distress in the surrogates and indirectly induced negative feelings during decision-making.
Each surrogate considered the patient an angel that the family needed to be complete. The family members described how their memories of the patient, whether happy or sad, were bits and pieces of their lives. Their positive and negative emotions coincided with positive and negative changes in the condition of the patient, and they expressed fears of being alone if the patient left them. The Confucian value system evolved from the need to maintain complex social relationships and to guide behavior and interactions among family members. That is, Confucian guidelines for behavior and conduct are intended to maintain strong family relationships and good public perceptions. Compared to westerners, however, Chinese populations tend to be more reserved in their expressions of love and other emotions. The results revealed that surrogates informally tended to avoid discussing certain highly stressful matters such as a perceived lack of family support, a poor relationship with the patient, and progression of the disease from onset to ICU admission. Ji (2012) used a phenomenological methodology and performed in-depth interviews to explore the experience of nine surrogates of ICU patients. The theme of “Being in a constantly fearful and pressured state” and its subtheme of “Family member and medical activity assistance” emerged in their study. The authors described how insufficient family support and conflicts between the family and the medical staff can induce negative feelings such as fear and psychological distress [
28].
Surrogates of certain populations such as DINKs or new immigrants may feel extreme mental and physical exhaustion when no other relatives or friends are available to provide support and assistance. For many populations, especially in Asia, children are expected to provide lifelong care and support for their parents. However, this responsibility can be a heavy emotional burden. The emotional longings and desires of surrogates of cancer patients are rarely considered by the medical team, and limited ICU visiting hours deprive surrogates of their emotional bonds with the patients. The ICU team can help them by referring them for psychotherapy or other social services or by encouraging them to seek emotional support from friends and relatives.
The major sources of negative emotions for surrogates in this study were the limited visiting hours and the enclosed environment of the ICU, which deprived surrogates and patients of their emotional connection and caused a constant yearning for each other. This feeling of yearning, coupled with changes in the physical appearance of the patients related to disease or treatment, often caused the surrogates to experience tension and shock, which impaired their relationship with the medical team. Disrupted communication and connection with an ICU patient can cause family members to lose confidence in their ability to make healthcare decisions [
15]. The needs and longings of surrogates are not prioritized by medical teams. For example, medical personnel who are focused on providing rapid and effective treatment for an ICU patient may not have time or energy to consider the psychological distress experienced by a surrogate who observes physical changes in the patient, such as large surgical wounds, severe bruises, or edema caused by procedures such as endotracheal intubation or repeated placement of other invasive devices. Surrogates who perceive a lack of concern about their distress may then experience feelings of resentment, which can negatively affect their decision-making capability and cause them to experience doubt and unease about the medical team. These changes can cause negative emotions such as sadness and regret as well as suspicion about the competency of the medical team [
29,
30].
This study revealed that conflicts between rationality and sentimentality can impair decision-making, not only when the surrogate perceives a gap between the knowledge of the medical team and the information the medical team actual conveys, but also when the surrogate experiences complex emotional entanglements with the patient. Dionne-Odom et al. (2015) explored and compared decision-making processes in surrogates for ICU patients in their last stages of life [
16]. The discussed how surrogate decision-making is affected by painful affections uncertainty about the medical treatment due to a knowledge gap, e.g., a surrogate may be concerned that the patient cannot tolerate a painful medical procedure. Specifically, the author discussed how “painful affections” decrease the willingness of surrogates to authorize further treatment for the patient. For surrogates, these relationships and entanglements resemble a net with which the surrogate must disassociate in order to make a rational decision.
The interview results also revealed that a struggle for power among family members often causes conflict during the decision-making process. Family demands are a well-recognized phenomenon in the “moral and emotional concepts” factor. Surrogates must consider the demands and expectations of all family members so that the treatment decision is consensual [
16]. Su (2014) conducted focus group interviews with 69 surrogates and found that communication, emotions, and conflicts are the three most important factors in the surrogate decision-making process. The struggle for power among family members with different thoughts on medical treatment for the patient is a major cause of conflict during the decision-making process [
5,
18] Therefore, support from family members is essential for effective surrogate decision-making. However, displays of affection and emotions such as love and gratitude are much more restrained in Chinese culture in comparison with western culture [
31]. Health professionals can improve the decision-making process and help families reach a consensus by referring them for counseling. A notable cultural difference in surrogate decision-making is that surrogates in Asia tend to consider the feelings and concerns of other family members and the need to reach a consensus. In contrast, surrogates in other countries tend to focus on choosing the best treatment option for the patient. For medical teams, the main concern is rapidly and efficiently diagnosing the patient and then providing treatment in the high-stress and fast-paced environment of an ICU. Communication with surrogates is not prioritized, which increases the risk of a decision-making conflict.
The risk of conflict can be reduced by clear communication that gives surrogates the information and confidence they need to understand evolving conditions during the decision-making process. Medical teams in ICUs should share their professional opinions with surrogates and should invite surrogates to ask questions about treatment. However, information should be presented in layman terms whenever possible. Visual aids can also be helpful for discussing technical matters. For example, radiologists often use simple drawings on paper or whiteboards to explain radiograph findings [
32]. The medical team should also schedule time to meet with surrogates and family members to discuss the medical plan, to address their concerns and needs, and to confirm their understanding [
32]. Scheduled meetings would also assist the family members and the surrogate in making consensual decisions.
Implications for Practice
We have four suggestions for decreasing surrogate decision-making conflict in the ICU. First, the ICU team should help surrogates by clarifying whether changes in physical appearance are short-term or long-term changes, especially after the patient undergoes an invasive procedure that substantially changes the physical appearance of the patient. Second, the ICU medical team should, as early as possible, identify surrogates who have limited support systems and refer them to social workers. Third, visiting hours for surrogates should be flexible. Flexible visiting hours would enable surrogates to maintain emotional bonds with ICU patients by providing opportunities to assist with simple tasks, e.g., sending text messages, and would enable surrogates to spend time caring for patients. Last, hospitals should provide a comfortable rest area near the ICU where the surrogate and the family can discuss medical information and treatment options.
A limitation of this study is that the sample was recruited from a single medical center, which limits the potential generalizability of the results. Factors that affect the decision-making process in healthcare surrogates may differ in other geographic regions due to differences in cultural characteristics and differences in ICU visitor policies and other hospital policies. Thus, this study should be replicated in samples of surrogates of cancer patients in ICUs in different hospital levels and in different geographic regions. All participants in this study were young or middle-aged adults, which is another limitation of this study. Additionally, the long duration of the interviews (40–60 min) may have inconvenienced or distressed the surrogates, which could have affected their interview responses. Another limitation is that, even when interviews were scheduled in advance, the emotional impact of external conditions (e.g., displays of emotional distress by other ICU visitors or a life-threatening condition observed in another ICU patient) at the time of the interview may have caused interview bias. To minimize data collection bias, future studies should perform two separate interviews for each participant. Observing the emotional impact of decision-making in healthcare surrogates, particularly in Chinese populations, is very challenging in quantitative research. Further studies are needed to perform qualitative research in a larger and more diverse population of ICU patients.