Skip to main content

Thank you for visiting You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

Optimism bias in understanding neonatal prognoses



Discrepancies between physician and parent neonatal prognostic expectations are common. Optimism bias is a possible explanation.

Study design

Parents interpreted hypothetical neonatal prognoses in an online survey.


Good prognoses tended to be interpreted accurately, while poor prognoses were interpreted as less than the stated value. One-third of participants consistently overstated survival for the three lowest prognoses, compared to the sample as a whole. Three significant predictors of such optimistic interpretations were single-parent status (OR 0.39; 95% CI 0.2–0.75; p = 0.005), African-American descent (OR 3.78; 95% CI 1.63–8.98; p = 0.002) and the belief that physicians misrepresented prognoses (OR 3.11; 95% CI 1.47–6.65; p = 0.003). Participants’ explanations echoed research on optimism bias in clinical and decision science studies.


Participants accepted positive prognoses for critically ill neonates, but reinterpreted negative ones as being unduly pessimistic demonstrating optimism bias.

Access options

Rent or Buy article

Get time limited or full article access on ReadCube.


All prices are NET prices.

Fig. 1: Box plots for difference between participants’ assessments of survival probability and stated prognosis.


  1. 1.

    Boyd EA, Lo B, Evans LR, Malvar G, Apatira L, Luce JM, et al. “It’s not just what the doctor tells me:” factors that influence surrogate decision-makers’ perceptions of prognosis. Crit Care Med. 2010;38:1270–5.

    PubMed  PubMed Central  Google Scholar 

  2. 2.

    Bastek TK, Richardson DK, Zupancic JA, Burns JP. Prenatal consultation practices at the border of viability: a regional survey. Pediatrics. 2005;116:407–13.

    PubMed  Google Scholar 

  3. 3.

    Haward MF, Gaucher N, Payot A, Robson K, Janvier A. Personalized decision making: practical recommendations for antenatal counseling for fragile neonates. Clin Perinatol. 2017;44:429–45.

    PubMed  Google Scholar 

  4. 4.

    Boss RD, Hutton N, Sulpar LJ, West AM, Donohue PK. Values parents apply to decision-making regarding delivery room resuscitation for high-risk newborns. Pediatrics. 2008;122:583–9.

    PubMed  Google Scholar 

  5. 5.

    Janvier A, Lorenz JM, Lantos JD. Antenatal counselling for parents facing an extremely preterm birth: limitations of the medical evidence. Acta Paediatr. 2012;101:800–4.

    PubMed  Google Scholar 

  6. 6.

    Haward MF, Janvier A, Lorenz JM, Fischhoff B. Counseling parents at risk of delivery of an extremely premature infant: differing strategies. AJOB Empir Bioeth. 2017;8:243–52.

    PubMed  Google Scholar 

  7. 7.

    Wolfe J, Klar N, Grier HE, Duncan J, Salem-Schatz S, Emanuel EJ, et al. Understanding of prognosis among parents of children who died of cancer: impact on treatment goals and integration of palliative care. JAMA. 2000;284:2469–75.

    CAS  PubMed  Google Scholar 

  8. 8.

    Cox CE, Martinu T, Sathy SJ, Clay AS, Chia J, Gray AL, et al. Expectations and outcomes of prolonged mechanical ventilation. Crit Care Med. 2009;37:2888–904.

    PubMed  PubMed Central  Google Scholar 

  9. 9.

    Sung L, Klaassen RJ, Dix D, Pritchard S, Yanofsky R, Ethier M, et al. Parental optimism in poor prognosis pediatric cancers. Psychooncology. 2009;18:783–8.

    PubMed  Google Scholar 

  10. 10.

    Mack JW, Cook EF, Wolfe J, Grier HE, Cleary PD, Weeks JC. Understanding of prognosis among parents of children with cancer: parental optimism and the parent-physician interaction. J Clin Oncol. 2007;25:1357–62.

    PubMed  Google Scholar 

  11. 11.

    Ford D, Zapka JG, Gebregziabher M, Hennessy W, Yang C. Investigating critically ill patients’ and families’ perceptions of likelihood of survival. J Palliat Med. 2009;12:45–52.

    PubMed  Google Scholar 

  12. 12.

    White DB, Ernecoff N, Buddadhumaruk P, Hong S, Weissfeld L, Curtis JR, et al. Prevalence of and factors related to discordance about prognosis between physicians and surrogate decision makers of critically Ill patients. JAMA. 2016;315:2086–94.

    CAS  PubMed  Google Scholar 

  13. 13.

    de Wit S, Donohue PK, Shepard J, Boss RD. Mother-clinician discussions in the neonatal intensive care unit: agree to disagree? J Perinatol. 2013;33:278–81.

    PubMed  Google Scholar 

  14. 14.

    Lee Char SJ, Evans LR, Malvar GL, White DB. A randomized trial of two methods to disclose prognosis to surrogate decision makers in intensive care units. Am J Respir Crit Care Med. 2010;182:905–9.

    PubMed  PubMed Central  Google Scholar 

  15. 15.

    Sisk BA, Kang TI, Mack JW. How parents of children with cancer learn about their children’s prognosis. Pediatrics. 2018;141:e20172241.

    PubMed  Google Scholar 

  16. 16.

    Boss RD, Lemmon ME, Arnold RM, Donohue PK. Communicating prognosis with parents of critically ill infants: direct observation of clinician behaviors. J Perinatol. 2017;37:1224–9.

    CAS  PubMed  PubMed Central  Google Scholar 

  17. 17.

    White DB, Carson S, Anderson W, Steingrub J, Bird G, Curtis JR, et al. A multicenter study of the causes and consequences of optimistic expectations about prognosis by surrogate decision-makers in ICUs. Crit Care Med. 2019;47:1184–93.

    PubMed  PubMed Central  Google Scholar 

  18. 18.

    Zier LS, Sottile PD, Hong SY, Weissfield LA, White DB. Surrogate decision makers’ interpretation of prognostic information: a mixed-methods study. Ann Intern Med. 2012;156:360–6.

    PubMed  PubMed Central  Google Scholar 

  19. 19.

    Fischhoff B, Broomell SB. Judgment and decision making. Annu Rev Psychol. 2020;71:331–55.

    PubMed  Google Scholar 

  20. 20.

    Kahneman D. Thinking, fast and slow. New York: Farrar Straus & Giroux; 2011.

    Google Scholar 

  21. 21.

    Lerner JS, Li Y, Valdesolo P, Kassam KS. Emotion and decision making. Annu Rev Psychol. 2015;66:799–823.

    PubMed  Google Scholar 

  22. 22.

    Feudtner C, Walter JK, Faerber JA, Hill DL, Carroll KW, Mollen CJ, et al. Good-parent beliefs of parents of seriously ill children. JAMA Pediatr. 2015;169:39–47.

    PubMed  PubMed Central  Google Scholar 

  23. 23.

    Fischhoff B, Barnato AE. Value awareness: a new goal for end-of-life decision making. MDM Policy Pract. 2019;4:2381468318817523.

    PubMed  PubMed Central  Google Scholar 

  24. 24.

    Weinstein ND. Optimistic biases about personal risks. Science. 1989;246:1232–3.

    CAS  PubMed  Google Scholar 

  25. 25.

    Weinstein ND. Unrealistic optimism about future life events. J Pers Soc Psychol. 1980;39:806–20.

    Google Scholar 

  26. 26.

    Weinstein ND. Unrealistic optimism about susceptibility to health problems. J Behav Med. 1982;5:441–60.

    CAS  PubMed  Google Scholar 

  27. 27.

    Radcliffe NM, Klein WMP. Dispositional, comparative and unrealistic optimism. differential relations with the knowledge and processing of risk information and beliefs about person risk. Pers Soc Psychol Bull. 2002;28:836–46.

    Google Scholar 

  28. 28.

    Quadrel MJ, Fischhoff B, Davis W. Adolescent (in)vulnerability. Am Psychol. 1993;48:102–16.

    CAS  PubMed  Google Scholar 

  29. 29.

    Weeks JC, Cook EF, O’Day SJ, Peterson LM, Wenger N, Reding D, et al. Relationship between cancer patients’ predictions of prognosis and their treatment preferences. JAMA. 1998;279:1709–14.

    CAS  PubMed  Google Scholar 

  30. 30.

    Haward MF, Murphy RO, Lorenz JM. Message framing and perinatal decisions. Pediatrics. 2008;122:109–18.

    PubMed  Google Scholar 

  31. 31.

    Gamble VN. Under the shadow of Tuskegee: African Americans and health care. Am J Public Health. 1997;87:1773–8.

    CAS  PubMed  PubMed Central  Google Scholar 

  32. 32.

    Institute of Medicine. Unequal treatment: confronting racial and ethnic disparities in health care. Washington, DC: National Academics Press; 2003.

    Google Scholar 

  33. 33.

    Walker RJ, Strom Williams J, Egede LE. Influence of race, ethnicity and social determinants of health on diabetes outcomes. Am J Med Sci. 2016;351:366–73.

    PubMed  PubMed Central  Google Scholar 

  34. 34.

    Patel D, Cohen ED, Barnato AE. The effect of framing on surrogate optimism bias: a simulation study. J Crit Care. 2016;32:85–8.

    PubMed  Google Scholar 

  35. 35.

    Reder EA, Serwint JR. Until the last breath: exploring the concept of hope for parents and health care professionals during a child’s serious illness. Arch Pediatr Adolesc Med. 2009;163:653–7.

    PubMed  Google Scholar 

  36. 36.

    Arnolds M, Xu L, Hughes P, McCoy J, Meadow W. Worth a try? describing the experiences of families during the course of care in the neonatal intensive care unit when the prognosis is poor. J Pediatr. 2018;196:116–22.e3.

    PubMed  Google Scholar 

  37. 37.

    Geros-Willfond KN, Ivy SS, Montz K, Bohan SE, Torke AM. Religion and spirituality in surrogate decision making for hospitalized older adults. J Relig Health. 2016;55:765–77.

    PubMed  Google Scholar 

  38. 38.

    Robinson MR, Thiel MM, Backus MM, Meyer EC. Matters of spirituality at the end of life in the pediatric intensive care unit. Pediatrics. 2006;118:e719–29.

    PubMed  Google Scholar 

  39. 39.

    Sharot T. The optimism bias. Curr Biol. 2011;21:R941–5.

    CAS  PubMed  Google Scholar 

  40. 40.

    Blumenthal-Barby JS, Ubel PA. In defense of “Denial”: difficulty knowing when beliefs are unrealistic and whether unrealistic beliefs are bad. Am J Bioeth. 2018;18:4–15.

    CAS  PubMed  Google Scholar 

  41. 41.

    Janvier A, Leblanc I, Barrington KJ. Nobody likes premies: the relative value of patients’ lives. J Perinatol. 2008;28:821–6.

    CAS  PubMed  Google Scholar 

  42. 42.

    Janvier A, Mercurio MR. Saving vs creating: perceptions of intensive care at different ages and the potential for injustice. J Perinatol. 2013;33:333–5.

    PubMed  Google Scholar 

  43. 43.

    Barnato AE, Arnold RM. The effect of emotion and physician communication behaviors on surrogates’ life-sustaining treatment decisions: a randomized simulation experiment. Crit Care Med. 2013;41:1686–91.

    PubMed  PubMed Central  Google Scholar 

  44. 44.

    Haward MF, Murphy RO, Lorenz JM. Default options and neonatal resuscitation decisions. J Med Ethics. 2012;38:713–8.

    PubMed  Google Scholar 

  45. 45.

    Guillén Ú, Mackley A, Laventhal N, Kukuro S, Christ L, Derrick M, et al. Evaluating the use of a decision aid for parents facing extremely premature delivery: a randomized trial. J Pediatr. 2019;209:52–60.e1.

    PubMed  PubMed Central  Google Scholar 

  46. 46.

    Moore GP, Lemyre B, Daboval T, Ding S, Dunn S, Akiki S, et al. Field testing of decision coaching with a decision aid for parents facing extreme prematurity. J Perinatol. 2017;37:728–34.

    CAS  PubMed  Google Scholar 

  47. 47.

    Guillen U, Kirpalani H. Ethical implications of the use of decision aids for antenatal counseling at the limits of gestational viability. Semin Fetal Neonatal Med. 2018;23:25–9.

    PubMed  Google Scholar 

  48. 48.

    Peerzada JM, Richardson DK, Burns JP. Delivery room decision-making at the threshold of viability. J Pediatr. 2004;145:492–8.

    PubMed  Google Scholar 

  49. 49.

    Blanco F, Suresh G, Howard D, Soll R. Ensuring accurate knowledge of prematurity outcomes for prenatal counseling. Pediatrics. 2005;115:e478–87.

    PubMed  Google Scholar 

  50. 50.

    Zupancic J, Kirpalani H, Barrett J, Stewart S, Gafni A, Streiner D. et al. Characterising doctor–patient communication in counselling for impending preterm delivery. Arch Dis Child Fetal Neonatal Ed. 2002;87:F113–7.

    CAS  PubMed  PubMed Central  Google Scholar 

  51. 51.

    Dupont-Thibodeau A, Barrington KJ, Farlow B, Janvier A. End-of-life decisions for extremely low-gestational-age infants: why simple rules for complicated decisions should be avoided. Semin Perinatol. 2014;38:31–7.

    PubMed  Google Scholar 

  52. 52.

    Lemmon ME, Huffstetler H, Barks MC, Kirby C, Katz M, Ubel P, et al. Neurologic outcome after prematurity: perspectives of parents and clinicians. Pediatrics. 2019;144:e20183819.

    PubMed  PubMed Central  Google Scholar 

Download references


The authors would like to thank Deborah Campbell, MD and the Division of Neonatology at Montefiore Children’s Hospital Albert Einstein College of Medicine for their support of this research.


Division of Neonatology fellow research funds.

Author information




All authors contributed in the design, data analysis, and paper development and revision.

Corresponding author

Correspondence to Marlyse F. Haward.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Nayak, B., Moon, JY., Kim, M. et al. Optimism bias in understanding neonatal prognoses. J Perinatol 41, 445–452 (2021).

Download citation

Further reading


Quick links