Drs. Courtright and Halpern Discuss Nudges for Prognosis and Comfort Care in the ICU on the GeriPal Podcast

From GeriPal:

“Our main focus today was on nudging critical care clinicians to consider a more palliative approach to care. Our guests are all trained in critical care: Kate Courtright, Scott Halpern, and Jaspal Singh. Kate and Scott have additional training in palliative medicine.

To start, we review:
* What is a nudge? Also called behavioral interventions, heuristics, and cognitive biases.
* Prior podcasts on the ethics of nudging, and a different trial conducted by Kate and Scott in which the default for hospitalized seriously ill patients was to receive a palliative care consult.
* What is sludge? I’d never heard the term, perhaps outside of Eric’s pejorative reference to my coffee after adding copious creamers, flavoring, and sweeteners. Sludge is apparently when you create barriers or extra work for someone. For example, putting the healthy food at the back of the grocery store is sludge; making an applicant for health insurance climb the flight of stairs to the office – weeding out those less fit – is also sludge. Prior-auth forms? Sludge.
* Examples of nudges, some based in health care, others in coffee.

This specific study, published in JAMA Internal Medicine, was conducted in 17 ICUs in North Carolina. Many were community hospitals. Participants were critically ill and intubated. Clinicians were randomized to 4 groups: (1) Usual care, (2) Prognosis nudge – EHR prompt asking, do you think your patient will be alive in 6 months? This is called a focusing effect, (3) Comfort care nudge – EHR prompt asking if they’d offered comfort-focused care. This is called accountable justification – an appeal to standards of care for critically ill patients endorsed by multiple professional societies, (4) Both the prognosis and comfort care nudge.”