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

Abstract Background Surrogate decision-makers are called upon to act for millions of adults who can no longer direct their own care, yet the factors that shape their confidence remain understudied. Most research has focused on acute clinical settings, leaving general, everyday surrogate decision-making largely overlooked. This study investigated whether surrogate decision-making confidence varies by decision type and identified cognitive, psychological, experiential, and demographic predictors of that confidence. Methods An online survey (N = 301) administered via Amazon Mechanical Turk presented participants with eight surrogate decision-making scenarios: four general (routine decisions) and four acute (high-stakes, time-sensitive, or ethically complex decisions). Confidence was rated on a 5-point Likert scale. We isolated predictors for each outcome using a four-step hierarchical multiple regression. Variables were entered sequentially in the following blocks: (1) demographics, (2) cognitive reflection, (3) self-efficacy, and (4) decision-making and caregiving experience. Qualitative ethics coding using the four principles identified by Beauchamp and Childress applied to two purposively selected scenarios. Results Participants reported significantly higher confidence for general decisions (M = 3.78, SD = 0.73) than for acute decisions (M = 3.12, SD = 0.77), t(300) = 16.68, p < 0.001, d = 0.96. Self-efficacy was the strongest predictor of confidence in both outcome types (Acute Scenario: β = 0.426, p < 0.001 and General Scenario: β = 0.393, p < 0.001). Higher cognitive reflection predicted lower acute confidence (β = −0.141, p = 0.017). Race/ethnicity (β = −0.162, p = 0.006) and income (β = 0.196, p = 0.001) predicted general but not acute confidence. For both the general and acute scenarios, ethics coding revealed that autonomy and beneficence were the dominant principles applied across both scenario types, with nonmaleficence more prominent in the acute scenario. Conclusions Surrogate decision-making confidence is systematically sensitive to decision type and is shaped by modifiable individual characteristics, particularly self-efficacy. 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.