BACKGROUND: Global aging has increased the reliance on surrogates to make health care decisions for others. We investigated the differences between making health care decisions and predicting health care decisions, self-other differences for made and predicted health care decisions, and the roles of perceived social norms, emotional closeness, empathy, age, and gender. METHODS: = 2037) from a nationally representative US panel were randomly assigned to make or to predict a health care decision. They were also randomly assigned to 1 of 5 recipients: themselves, a loved one 60 y or older, a loved one younger than 60 y, a distant acquaintance 60 y or older, or a distant acquaintance younger than 60 y. Hypothetical health care scenarios depicted choices between relatively safe lower-risk treatments with a good chance of yielding mild health improvements versus higher-risk treatments that offered a moderate chance of substantial health improvements. Participants reported their likelihood of choosing lower- versus higher-risk treatments, their perceptions of family and friends' approval of risky health care decisions, and their empathy. RESULTS: We present 3 key findings. First, made decisions involved less risk taking than predicted decisions, especially for distant others. Second, predicted decisions were similar for others and oneself, but made decisions were less risk taking for others than oneself. People predicted that loved ones would be less risk taking than distant others would be. Third, perceived social norms were more strongly associated than empathy with made and predicted decisions. LIMITATIONS: Hypothetical scenarios may not adequately represent emotional processes in health care decision making. CONCLUSIONS: Perceived social norms may sway people to take less risk in health care decisions, especially when making decisions for others. These findings have implications for improving surrogate decision making. HIGHLIGHTS: People made less risky health care decisions for others than for themselves, even though they predicted others would make decisions similar to their own. This has implications for understanding how surrogates apply the substituted judgment standard when making decisions for patients.Perceived social norms were more strongly related to decisions than treatment-recipient (relationship closeness, age) and decision-maker (age, gender, empathy) characteristics. Those who perceived that avoiding health care risks was valued by their social group were less likely to choose risky medical treatments.Understanding the power of perceived social norms in shaping surrogates' decisions may help physicians to engage surrogates in shared decision making.Knowledge of perceived social norms may facilitate the design of decision aids for surrogates.
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