Date of Degree


Document Type


Degree Name



Nursing Studies


Marianne Jeffreys

Subject Categories

Ethics and Political Philosophy | Nursing | Public Health Education and Promotion


allow natural death, do not resuscitate, end of life communication, framing, I am PreparedTM, surrogate decision maker


This study investigated the relationship between end of life terminologies and decisional conflict in surrogate decision makers using a convenience sample of 234 adults age 50 and older at active adult communities, and senior centers in New Jersey. Participants were randomized into two groups, and each received a vignette that was personalized. The vignettes varied only in the use of the words "Do Not Resuscitate (DNR)" and "Allow Natural Death (AND)". The Decisional Conflict Scale (DCS) was administered.

There was no difference in total DCS score based on AND and DNR versions. However, AND respondents perceived their decision as a good decision, and were eight times more likely to sign the document than DNR participants, indicating that framing influences surrogate decision making at the end of life. Those who frequently attended religious services were twice as likely as those who rarely attend religious services of implementing their decision; whether the decision is to sign or not to sign the AND or DNR.

Experienced decision makers (EDMs) evolved as a discreet group. They had lower mean total DCS scores and lower mean subscores, indicating that prior experience is an important aspect of end of life decision making. Additionally, AND and EDM participants were more likely to perceive their decision as good and were more likely to be to be sure of their decision, indicating that experienced decision makers respond more favorably to the words Allow Natural Death. The term AND lead to increased likelihood of actually making a decision. Respondents to the DNR version were likely to not sign or postpone signing. Finally, participants were more likely to withdraw from the study when the term DNR was used.

Recommendations for end of life educational enhancements of nursing faculty, students, registered nurses, and all health care professionals are presented. Policy changes to increase public awareness and create a surrogate data base are recommended. The I am PreparedTM program is introduced. Future research is needed to improve adoption of advance directives and assist communication to help the dying and the surrogate decision makers that they leave behind.