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Surrogate Decision-Making Confidence Across Acute and General Scenarios: Predictors and Ethical Reasoning in a Mixed-Methods Study

This mixed-methods study reveals that surrogate decision-makers report significantly lower confidence in acute scenarios compared to general ones, with self-efficacy emerging as the strongest predictor of confidence across both contexts, suggesting that targeted preparation to boost self-efficacy could improve decision-making readiness.

Original authors: Yuxin Zhao, Onyinye Mbanefo, Sean Lawrence, Nethra Rajeshkumar, Emily Jon, Benjamin Katz, Pamela Teaster

Published 2026-07-07

📖 5 min read🧠 Deep dive

CC BY 4.0

Original authors: Yuxin Zhao, Onyinye Mbanefo, Sean Lawrence, Nethra Rajeshkumar, Emily Jon, Benjamin Katz, Pamela Teaster

Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). ✨ This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer

The Big Picture: The "Surrogate" Role

Imagine you are the captain of a ship, but the ship belongs to someone else who has fallen asleep or lost their voice. You have to steer the ship for them. In real life, this happens when a family member has to make medical or financial decisions for a loved one who can't do it themselves. These people are called surrogate decision-makers.

This study wanted to know: How confident do these "captains" feel? And does it matter if the storm is a gentle breeze (a routine task) or a hurricane (a life-or-death emergency)?

The Experiment: Two Types of Storms

The researchers asked 301 people to imagine themselves in eight different situations where they had to make a decision for someone else. They split these situations into two categories:

The "Gentle Breeze" (General Scenarios): These are routine, everyday headaches.
- Example: Your mom is lonely and wants you to cancel your vacation to visit her. Or, your dad has a dispute with his insurance company.
- The Vibe: Annoying, maybe a bit stressful, but not dangerous.
The "Hurricane" (Acute Scenarios): These are high-stakes, urgent, and scary situations.
- Example: Your brother is terminally ill, suicidal, and refusing to eat. Or, your elderly dad is driving dangerously and neglecting to buy food.
- The Vibe: Life-or-death, time-sensitive, and emotionally heavy.

The Main Findings

1. Confidence Drops When the Storm Hits

The results were clear: People felt much more confident handling the "Gentle Breezes" than the "Hurricanes."

General Decisions: Average confidence was high (3.78 out of 5).
Acute Decisions: Confidence dropped significantly (3.12 out of 5).
The Takeaway: Just like a driver feels more confident parking in an empty lot than navigating a blizzard, surrogates feel much more capable when the stakes are lower.

2. The "Inner Muscle" Matters Most (Self-Efficacy)

The study looked at what makes a person feel confident. The biggest factor wasn't how much money they had or their race; it was Self-Efficacy.

The Analogy: Think of self-efficacy as your "inner gym muscle" for handling stress. It's your belief that you can handle tough situations.
The Result: Whether the situation was a routine insurance call or a life-or-death medical crisis, the people with the strongest "inner muscle" felt the most confident. If you believe you can cope, you feel ready to make the call, no matter how scary the situation is.

3. The "Over-Thinker" Paradox

The study found something interesting about people who are very good at thinking things through (measured by a test called the Cognitive Reflection Test).

The Finding: In the "Hurricane" scenarios, the more analytical and reflective a person was, the less confident they felt.
The Analogy: Imagine a chess player. A novice might feel super confident making a move because they don't see all the risks. A grandmaster, however, sees ten different ways the game could go wrong. Because they see the complexity and the unknowns, they feel less sure-footed.
The Result: Being smart and reflective made people realize how much they didn't know in high-stakes situations, which lowered their confidence. This didn't happen with routine tasks.

4. Money and Race Only Help with the "Gentle Breezes"

General Decisions: People with higher incomes and non-White participants felt more confident handling routine tasks (like insurance or scheduling). The researchers suggest this might be because higher income helps you navigate complex systems (like banks or insurance), and some cultures rely more heavily on family networks for daily care.
Acute Decisions: Once the situation became a "Hurricane" (life-or-death), money and race stopped predicting confidence. In a crisis, everyone feels the same level of fear, and only that "inner muscle" (self-efficacy) matters.

The "Moral Compass" Check

The researchers also looked at why people made the choices they did, using four ethical rules (like "do no harm" or "respect freedom").

In the Vacation Scenario (General): People tried to balance Freedom (doing what they wanted) and Kindness (helping their mom). They looked for "win-win" solutions, like bringing the mom on the trip or visiting later.
In the Driving Scenario (Acute): The focus shifted almost entirely to Kindness (protecting the dad from harm) and Not Doing Harm (stopping him from crashing). People were willing to take away the dad's freedom (his car keys) to keep him safe.

The Bottom Line

This study tells us that being a surrogate decision-maker is a different game depending on the stakes.

When things are routine, your background (money, culture) and experience help you feel ready.
When things are critical, those external factors fade away. The only thing that really matters is your belief in your own ability to cope.

The authors suggest that if we want to help people be better surrogates, we shouldn't just teach them medical facts. Instead, we should help them build that "inner muscle" of confidence before a crisis hits, so they feel ready for both the gentle breezes and the hurricanes.

Technical Summary: Surrogate Decision-Making Confidence Across Acute and General Scenarios

Problem Statement
Surrogate decision-makers are frequently called upon to act for millions of adults who lack the capacity to direct their own care, yet the factors shaping their confidence in these roles remain understudied. Existing literature has predominantly focused on acute clinical settings (e.g., end-of-life care, intensive care), leaving general, everyday surrogate decision-making largely overlooked. Furthermore, no prior study has directly compared surrogate decision confidence across general (routine) and acute (high-stakes) decision types using a scenario-based methodology, nor have individual-level predictors (cognitive, psychological, experiential, and demographic) been examined simultaneously across both decision contexts. This study addresses these gaps by investigating whether confidence varies by decision type and identifying the predictors of that confidence.

Methodology
The study employed a mixed-methods approach with a sample of $N=301$ participants recruited via Amazon Mechanical Turk.

Design: An online survey presented participants with eight surrogate decision-making scenarios: four "general" (routine, low-urgency tasks) and four "acute" (high-stakes, time-sensitive, or ethically complex situations).
Measures:
- Confidence: Rated on a 5-point Likert scale for each scenario.
- Predictors: Demographics (age, gender, race/ethnicity, education, income), Cognitive Reflection (measured via the 3-item Cognitive Reflection Test, CRT), Self-Efficacy (measured via the 10-item General Self-Efficacy Scale, GSE), and binary variables for prior decision-making experience and current caregiving status.
- Ethical Coding: Participants provided open-ended rationales for two purposively selected scenarios (one general, one acute). These were qualitatively coded by a team trained in Beauchamp and Childress's four ethical principles (autonomy, beneficence, nonmaleficence, justice).
Analysis:
- Quantitative: A four-step hierarchical multiple regression was conducted separately for acute and general confidence outcomes. Predictors were entered in blocks: (1) demographics, (2) CRT, (3) GSE, and (4) experience variables.
- Qualitative: Thematic analysis of open-ended responses was conducted to identify dominant ethical principles.

Key Results

Confidence Variation: Participants reported significantly higher confidence for general decisions ( $M=3.78$ ) compared to acute decisions ( $M=3.12$ ), $t(300)=16.68, p<0.001, d=0.96$ .
Predictors of Confidence:
- Self-Efficacy: This was the strongest predictor of confidence for both decision types. In the final models, self-efficacy accounted for the largest increment in explained variance ( $\Delta R^2 = 0.170$ for acute; $\Delta R^2 = 0.144$ for general).
- Cognitive Reflection (CRT): Higher CRT scores predicted lower confidence in acute scenarios ( $\beta = -0.141, p=0.017$ ) but did not significantly predict general confidence. This suggests a "calibration effect" where reflective individuals are more aware of their knowledge limits in high-stakes situations.
- Demographics: Race/ethnicity and income predicted general confidence but not acute confidence. Specifically, non-White participants reported higher general confidence than White participants, and higher income correlated with higher general confidence. These effects disappeared in acute scenarios.
- Experience: Prior decision-making and caregiving experience did not significantly predict confidence in the final models for either scenario type.
Ethical Reasoning:
- General Scenarios: Autonomy and beneficence were the dominant principles, often co-occurring. Participants frequently sought "win-win" solutions balancing personal rights with the care recipient's needs.
- Acute Scenarios: Beneficence became the dominant principle, followed by autonomy and nonmaleficence. The tension between protecting a vulnerable person and respecting their right to take risks was more pronounced.

Key Contributions

Empirical Distinction: The study provides evidence that surrogate decision-making confidence is systematically sensitive to decision type, with acute scenarios eliciting significantly lower confidence than general scenarios.
Predictive Modeling: It identifies self-efficacy as the most robust, modifiable predictor of confidence across all contexts, while highlighting that cognitive reflection has a paradoxical negative association with confidence specifically in high-stakes acute situations.
Contextual Nuance: The findings demonstrate that demographic factors (race, income) influence confidence in routine decisions but are overshadowed by psychological resources (self-efficacy) and cognitive processing (reflection) in crisis situations.
Ethical Landscape: The qualitative coding reveals a shift in ethical reasoning from a balance of autonomy and beneficence in routine tasks to a dominance of beneficence in acute crises, mirroring professional healthcare tensions.

Significance and Claims
The authors claim that surrogate decision-making confidence is shaped by modifiable individual characteristics, particularly self-efficacy. They posit that preparation efforts targeting general coping confidence, delivered before crises arise in community and clinical settings, may meaningfully improve surrogate decision-making readiness across both routine and high-stakes decisions. The study suggests that interventions should focus on bolstering the belief in one's capacity to cope with demanding situations, as this belief transfers directly to decision-making confidence regardless of the scenario's stakes. The authors modestly note that while their findings elucidate correlates of confidence, the classification of scenarios was based on theoretical judgment, and future work is needed to further validate these categories and explore additional psychological mechanisms.