Presenter Status
Fellow
Abstract Type
Research
Primary Mentor
Laura Miller-Smith
Start Date
10-5-2021 11:30 AM
End Date
10-5-2021 1:30 PM
Presentation Type
Poster Presentation
Description
Background: Nudging is a behavioral economics term describing a form of choice architecture that affects behavior without eliminating options. Shared decisions with families are made frequently in the PICU during care conferences, where nudging likely occurs, but has not been studied.
Objectives/Goal: We aimed to identify how pediatric intensivists use nudging to guide decision making.
Methods/Design: We conducted a retrospective analysis of 70 PICU care conference transcripts using a validated coding scheme for choice architecture. Choice frames included: saliency, gain loss or mixed frame, yes/no, two options, multiple options, open ended, default, endowment, commission, omission, recommend, expert opinion, certainty, and social norming. Frequency of nudging types used for decision-making were analyzed by three research team members until consistency was achieved. Then each transcript was coded separately by 2 team members, confirmed through discussion with the coding team. We analyzed the frequency with which types of clinicians used each type of choice frame, defining each transcript as a unit of analysis.
Results: We identified 309 decision episodes across the 63 included transcripts, with an average of 4.9 decision episodes per care conference. Tracheostomy was the most common decision discussed, occurring in 62% of conferences. Other decisions were made regarding gastrostomy tubes, redirecting goals of care (eg DNR status or hospice) and medication or treatment decisions like chemotherapy or procedural interventions. We identified 1095 nudges in these 63 transcripts, with between 2 and 14 in each conference. Pediatric intensivists used nudging in all studied interactions. They most commonly used “framing”, choosing “gain frame” over “loss frame” and “mixed frame”, thereby putting emphasis on how a patient can benefit rather than how they may be harmed. Expert opinion was used the least frequently, along with positive and negative saliency. Surgical specialists nudged in 100% of conferences attended, and were more likely to utilize two options, default, and gain and loss frame. Palliative care was more likely to utilize social norming along with gain and loss frame. Bedside nurses nudged in 0 out of 12 attended conferences.
Conclusions: Overall, clinicians utilized nudging regularly to guide surrogate decision making, most frequently using “framing” or “default” techniques. Interestingly, “expert opinion” was used most infrequently, followed by saliency and commission and omission. Understanding how intensivists utilize nudging can inform how we educate providers on the risks and benefits of these techniques.
MeSH Keywords
bioethics, nudging, choice architecture
Included in
Pediatric Intensivists' Use of Nudging in Care Conferences
Background: Nudging is a behavioral economics term describing a form of choice architecture that affects behavior without eliminating options. Shared decisions with families are made frequently in the PICU during care conferences, where nudging likely occurs, but has not been studied.
Objectives/Goal: We aimed to identify how pediatric intensivists use nudging to guide decision making.
Methods/Design: We conducted a retrospective analysis of 70 PICU care conference transcripts using a validated coding scheme for choice architecture. Choice frames included: saliency, gain loss or mixed frame, yes/no, two options, multiple options, open ended, default, endowment, commission, omission, recommend, expert opinion, certainty, and social norming. Frequency of nudging types used for decision-making were analyzed by three research team members until consistency was achieved. Then each transcript was coded separately by 2 team members, confirmed through discussion with the coding team. We analyzed the frequency with which types of clinicians used each type of choice frame, defining each transcript as a unit of analysis.
Results: We identified 309 decision episodes across the 63 included transcripts, with an average of 4.9 decision episodes per care conference. Tracheostomy was the most common decision discussed, occurring in 62% of conferences. Other decisions were made regarding gastrostomy tubes, redirecting goals of care (eg DNR status or hospice) and medication or treatment decisions like chemotherapy or procedural interventions. We identified 1095 nudges in these 63 transcripts, with between 2 and 14 in each conference. Pediatric intensivists used nudging in all studied interactions. They most commonly used “framing”, choosing “gain frame” over “loss frame” and “mixed frame”, thereby putting emphasis on how a patient can benefit rather than how they may be harmed. Expert opinion was used the least frequently, along with positive and negative saliency. Surgical specialists nudged in 100% of conferences attended, and were more likely to utilize two options, default, and gain and loss frame. Palliative care was more likely to utilize social norming along with gain and loss frame. Bedside nurses nudged in 0 out of 12 attended conferences.
Conclusions: Overall, clinicians utilized nudging regularly to guide surrogate decision making, most frequently using “framing” or “default” techniques. Interestingly, “expert opinion” was used most infrequently, followed by saliency and commission and omission. Understanding how intensivists utilize nudging can inform how we educate providers on the risks and benefits of these techniques.
