Caregivers Choose End-of-Life Options Based on Their Attachment Styles

More people will care for an aging parent in the coming years than ever before. Advances in modern medicine have extended life expectancy and the relationship between the aging and their caregivers, whether they are family members or not, is of critical importance. “Arguably, at no time is understanding care-seekers’ wishes more important than when care-seekers are incapacitated, especially when life-or-death decisions about medical interventions are required,” said Bulent Turan of the Department of Psychology at the University of Alabama, Birmingham, and lead author of a recent study. “In this study, we assessed surrogates’ decision makers’ accuracy in predicting their older relatives’ end-of-life health care wishes—whether they would choose intensive and painful life-sustaining procedures or would refuse those treatments in order to maximize the quality of their remaining life.”

Surrogates often base their decisions for life-sustaining or life-ending means on what they would choose for themselves. Another theory is that caregivers’ decisions for their loved ones are based on the attachment style that they possess. “A secure attachment orientation is characterized by comfort in support exchanges in relationships and by regarding the self as competent in dealing with stress,” said Turan. “There are two insecure attachment orientations: Attachment-related anxiety is characterized by chronic worries about relationship partners’ availability, and attachment-related avoidance is characterized by keeping emotional distance from close others.”

Turan interviewed caregivers and their family members and found that insecure attachment styles led to the wrong prediction of a patient’s final wishes. “It is interesting to note that even though surrogates’ attachment-related anxiety was associated with lower accuracy of end-of-life health care wishes of their loved ones, it was associated with higher accuracy in the non-stressful task of predicting their loved ones’ everyday living conditions,” said Turan. “Our findings have implications for interventions aimed at increasing surrogates’ accuracy and the quality of their caregiving. Changing surrogates’ attachment orientation may not be easy.” He added, “However, interventions can (a) focus on detecting surrogates’ emotional reactions and coping strategies when faced with the stressful possibility of making end-of-life decisions for loved ones (being overwhelmed or emotionally avoiding the topic) and (b) target the limiting emotion regulation strategies associated with insecure attachment orientations.”

Turan, Bulent, Mary K. Goldstein, Alan M. Garber, and Laura L. Carstensen. “Knowing Loved Ones’ End-of-life Health Care Wishes: Attachment Security Predicts Caregivers’ Accuracy.” Health Psychology 30.6 (2011): 814-18. Print.

© Copyright 2011 by By John Smith, therapist in Bellingham, Washington. All Rights Reserved. Permission to publish granted to

The preceding article was solely written by the author named above. Any views and opinions expressed are not necessarily shared by Questions or concerns about the preceding article can be directed to the author or posted as a comment below.

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  • Hilary Cohen

    Hilary Cohen

    December 9th, 2011 at 5:42 PM

    Any caregiver worth their salt has already discussed with their loved one what their wishes would be long before they get to the point where they are incapacitated and cannot verbalize them. If you’ve never had that conversation with those you love, do it today.

  • penny farr

    penny farr

    December 9th, 2011 at 7:11 PM

    It’s extremely tough if not impossible for a caregiver to be sure they are making the right call as to what their relative would want. You never know if they possibly changed their mind or not in the meantime.

    Of course, that decision needn’t be made any harder by interference. If other family members know for sure what they would have wanted, they should speak up. If they don’t, they should keep quiet unless asked for an opinion.

  • devoteddaughter


    December 9th, 2011 at 8:33 PM

    @penny: Ohhhh I hear you loud and clear!! It bugs me how older family members came out of the woodwork in my mother’s final few weeks wanting to direct everything, the very ones that could have offered support and help to me (the caregiver) and my mother during her long illness.

    All those months preceding it they were happy to allow me to carry the burden alone then suddenly wanted to look like they cared near the end. I know it was only in case there was money to be had, the bloodsuckers.

    Unfortunately you discover that’s not uncommon when you talk to other caregivers. Best thing you can do is find a caregiver support group. They are lifesavers and understand what it’s like.

  • Rosie Woodward

    Rosie Woodward

    December 9th, 2011 at 8:43 PM

    When my husband became ill, I made sure we had that talk. Our doctor had advised us to do so because it would take all the guesswork out of it for me if I needed to make hard choices on his behalf. I’m very glad she did. It’s stressful enough without having to wonder if you did the right thing.

  • clara s

    clara s

    December 10th, 2011 at 8:56 AM

    The important thing for all of us here is to see how critical it is for everyone to have a living will so that your last wishes will be carried out even after the time has come and gone and you are no longer able to make a rational decision for yourself. You may think that your caregiver knows what you want or will carry out those wishes based on what you would want. But I think that we have all seen situations where caregivers kind of lose focus on what the ailing person would want and focus instead on what they want. I know that it would be so hard to get past this especially if you are dealing with the end of the life of a close family member or even a spouse but think about what you would want to have done for you. This is not the time to be selfish but to be generous, and make the right decision for the person that you are taking care of.

  • DavidL


    December 10th, 2011 at 5:20 PM

    This is an ongoing issue. It is very important that you have state appropriate Advanced Directives and Living Will from your loved. Elder Law attorneys do this. If that’s not affordable try getting a copy of the “Five Wishes” which is a generic document that can take the guess work and pressure off the caregiver and stop all of the family’s “Monday Morning” Quarterbacking. If all else fails consult an Eldercare Mediator to help quantify the issues and options so the caregiver can make a wiser decision with less emotional reaction.

  • stressmom


    December 11th, 2011 at 12:00 PM

    hmmm this is curious that there are really that many caregivers who would put their own wishes ahead of the persons that they are taking care of. I guess it would be awfully difficult not to do that if this is family, or someone that you are close to. But think about it. If you are that close to them then why would you even consider putting what you want ahead of what they want? You can’t be so focused on you all of the time.

  • louis


    December 11th, 2011 at 12:13 PM

    well a lotta factors com into play when we speak bout this..such a choice wud firstly b based on d entire family n not one individual n if there is just one individual then friends n medical experts n various other things come into d picture..a person’s attachment style wud play a role but its not everything.

  • D.E. Velez

    D.E. Velez

    December 11th, 2011 at 5:27 PM

    I wouldn’t care what my wife decided because I know she would have my best interests at heart and base it upon all the years we’d spent together. I’d trusted her to look after me all throughout our life together. Why would I feel any different even if I couldn’t speak for myself? I know she would do the best she could for me.

  • Paul Malley

    Paul Malley

    December 12th, 2011 at 7:52 AM

    As commenter DavidL noted, one ought not have to guess about what a family member or loved one would want at or near the end of life. An advance directive allows the person him or herself to decide, thus avoiding the guessing and second-guessing that comes when wishes are not known. The largest impediment to completing an advance directive is that most state-supplied forms are written by doctors and lawyers and filled with medical and legal jargon that many don’t understand. Our Five Wishes advance directive is immensely popular (17 million in national circulation) because it lets people state their own wishes in their own words. Learn more at — Paul Malley, President, Aging with Dignity, a national non-profit organization.

  • Anna Louise

    Anna Louise

    December 12th, 2011 at 4:59 PM

    It gets harder and harder to know what the right thing to do is. You want to make everyone happy, including yourself, but that it is something that is going to be impossible to do. The best thing of all is to know the loved one that you have been charges with making decisions for and act in a way that is going to honor not only their wishes but that will help you to know that you sre doing the very best for them that you can.

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