Using default options and other nudges to improve critical care

As a second-year medical resident rotating through the Hospital of the University of Pennsylvania’s Medical ICU, I was struck by a seeming disconnect. Attending physicians instructed us to ensure that the heads of beds were elevated 30–45° for all mechanically ventilated patients, based on the best-available evidence. Yet, beds for newly admitted patients all started out flat. I wondered why, if head-of-bed elevation was good for most patients in our high-acuity ICU, did the ICU require residents to write orders for it ? Would it not be safer for nurses to elevate the beds automatically, unless residents wrote orders to flatten it (e.g., for the occasional patient, we admitted with acute stroke)? In other words, should not the preferred option for most patients be the default nursing practice?

Later that year, during morning rounds, I witnessed one of my favorite attending physicians depart from his normal approach to discussing whether to pursue cardiopulmonary resuscitation (CPR) with the wife of patient who was inexorably dying. He said to the wife, “In this situation, there is a real risk that his heart may stop. We would not normally do chest compressions in this situation because of how sick he is. Does that seem reasonable?” Though I would later learn that this choice of wording was spur-of-the-moment, it was clear to all observers how, by establishing a do-not-resuscitate order as a norm that would be enacted by default, the physician had made it easier for the wife to assent to a plan of no CPR.

These experiences motivated me to begin reading the primary literature on “nudges” or the intentional structuring of choice presentations or decision-making environments to increase the frequency of desired choices without removing any options. In this article, I summarize how nudges may improve the quality of care in the ICU and provide examples of ICU-based decisions that may be more effectively or ethically influenced by some nudges rather than others.