GeriPal - A Geriatrics and Palliative Care Podcast

Nudges for Prognosis and Comfort Care in the ICU: Kate Courtright, Scott Halpern, & Jaspal Singh


Listen Later

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.

A few key points of discussion:

  • Is an EHR prompt a nudge or sludge?  

  • The intervention was a negative study for the primary outcome, hospital length of stay.  Why? 

  • The prognosis nudge did nothing.  What to make of that? Would you think an EHR nudge to consider prognosis might move the needle, at least on some outcomes?

  • The nudge toward offering comfort care led to more hospice and early comfort-care orders.  Is this due to chance alone, given the multiplicity of secondary outcomes examined?  Or is it a tantalizing finding that suggests a remarkably low cost EHR based nudge might, on a population level, lead to critical care clinicians offering comfort care and hospice more frequently?  Imagine!  

 -Alex Smith

 

...more
View all episodesView all episodes
Download on the App Store

GeriPal - A Geriatrics and Palliative Care PodcastBy Alex Smith, Eric Widera

  • 4.9
  • 4.9
  • 4.9
  • 4.9
  • 4.9

4.9

273 ratings


More shows like GeriPal - A Geriatrics and Palliative Care Podcast

View all
JAMA Editors' Summary by JAMA Network

JAMA Editors' Summary

131 Listeners

JAMA Clinical Reviews by JAMA Network

JAMA Clinical Reviews

496 Listeners

AFP: American Family Physician Podcast by American Academy of Family Physicians

AFP: American Family Physician Podcast

706 Listeners

Mayo Clinic Talks by Mayo Clinic

Mayo Clinic Talks

281 Listeners

Frankly Speaking About Family Medicine by Pri-Med

Frankly Speaking About Family Medicine

253 Listeners

The Curbsiders Internal Medicine Podcast by The Curbsiders Internal Medicine Podcast

The Curbsiders Internal Medicine Podcast

3,336 Listeners

JAMA Medical News by JAMA Network

JAMA Medical News

90 Listeners

Core IM | Internal Medicine Podcast by Core IM Team

Core IM | Internal Medicine Podcast

1,095 Listeners

The Nocturnists by The Nocturnists

The Nocturnists

607 Listeners

Annals On Call Podcast by American College of Physicians

Annals On Call Podcast

185 Listeners

The Clinical Problem Solvers by The Clinical Problem Solvers

The Clinical Problem Solvers

519 Listeners

Harrison's PodClass: Internal Medicine Cases and Board Prep by AccessMedicine

Harrison's PodClass: Internal Medicine Cases and Board Prep

349 Listeners

Run the List by Walker Redd, Emily Gutowski, Navin Kumar, Joyce Zhou, Blake Smith

Run the List

248 Listeners

Cardionerds: A Cardiology Podcast by CardioNerds

Cardionerds: A Cardiology Podcast

427 Listeners

The Curious Clinicians by The Curious Clinicians

The Curious Clinicians

366 Listeners