Table 2.

Select themes and illustrative quotes about physicians’ objections to their peers approaches to negotiating with surrogates.

Objectionable approaches	Quotes
Misrepresenting information	“In some situations only one side of the coin is presented and the physician paints the picture in very dark colors…if the family sees some improvement in the patient a day or two later, this whole structure falls apart because now they understand that the physician was trying to tell them something that was not right.” “I think that certain physicians actually mislead families to believe that the prognosis is better than it is in order to continue to perform life prolonging treatment. Letting people die is not a good way to continue to bill them.” “I have seen some things which I think are just the wrong way to do it. One is to bring cost into it…I think that is also a very dangerous technique because for some, costs are very difficult to understand in medical care”
Imposing physician values	“I also don’t personally think the whole “if this were my dad I would do this” sort of motto is very appropriate…I see many physicians do that. “Well, I’ve seen religion being used as a way to convince people that they should stop an active therapy…that its time to go and God is calling. Which again without exploring the religious beliefs of the family and without good through knowledge of them I would never do that.” “I’ve certainly witnessed some physicians who will tell a surrogate “We are torturing this person, you must stop.” Essentially using some guilt in an overt way…”
Unprofessional behavior	“I remember a doctor…who was trying to describe someone’s downhill course and now, not content to make a mere analogy to a plane that was diving, crashing, but actually in the spur of the moment sort of reenacted this crash” “The worst thing I’ve seen is a physician, whether it was intentional or not, making a surrogate feel incapable or unworthy or unappreciated or stupid. You see that at times…it’s usually arrogance that leads to that.” “I have seen people go in and say “Your loved one is going to die and there’s nothing we can do about it”. It’s delivering the bad news or the unfavorable outcome in a cold, pragmatic, upfront manner… I think [surrogates] have a tough time with it.”