October 1, 2025 • 31 mins
Guiding patients and families in complex, high-stakes medical decisions, can we clinicians ever be truly neutral, or are we doomed to always nudge toward our own preferences and biases? How does the architecture of the decisions we present shape the choices that others make? Sarah and Dan tackle these questions and more with three nudging experts: Dr. Aliza Olive (Cleveland Clinic), Dr. Laura Miller-Smith (OHSU), and Dr. Joanna Hart (UPenn).
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Sarah Dabagh (00:01):
Hi, this is Sarah,
Daniel Eison (00:02):
and this is Dan,
Sarah Dabagh (00:03):
and we'd like to welcome you to PediPal,
Daniel Eison (00:07):
a podcast about all things pediatric palliative
care.
Sarah Dabagh (00:11):
The views in this podcast are ours alone and do
not represent our respectiveorganizations, nor do they
constitute medical advice.
Daniel Eison (00:18):
And this podcast really does cover all things
pediatric palliative care,symptom management, goals,
communication...
Sarah Dabagh (00:25):
I wonder if it might be helpful in this episode
to talk a little bit more aboutcommunication.
Daniel Eison (00:32):
Sarah, it seems like you're nudging me in a
certain direction.
Sarah Dabagh (00:35):
The actual concept of nudging is way more nuanced
than what we just attempted todo, very unsuccessfully. But I
wonder if we might introducethat as the topic for the
episode, and bring on somepeople who can talk about what
actual nudging looks like incommunication and how to use it
thoughtfully and how to be awareof it.
Aliza Olive (00:55):
Hi, I'm Aliza Olive. I'm a pediatric
intensivist at Cleveland Clinicchildren's in Cleveland, Ohio,
and I also study ethics andnudging.
Laura Miller-Smith (01:05):
I'm Laura Miller-Smith. I am also [a]
pediatric intensivist. I serveas the Chief of the Division of
Pediatric Critical Care Medicineand Medical Director of
Pediatric Cardiac Critical CareServices at Doernbecher
Children's Hospital, which ispart of Oregon Health and
Sciences University, and I havesome additional training in
bioethics.
Joanna Hart (01:25):
My name is Joanna Hart. I am an Assistant
Professor of Medicine andMedical Ethics and Health Policy
at the University ofPennsylvania. I am also an
intensivist. I work in the adultICUs as well as I am a general
adult pulmonologist as well.
Sarah Dabagh (01:41):
So I wonder if I can start with a question based
o (01:44):
In front of us, we have three intensivists. What about
intensive care lends itself mostto the study of nudging?
Aliza Olive (01:53):
I mean, nudging is very universal. It's everywhere.
I first learned about it from anethics webinar that John Lantos
did at Children's Mercy withJenny Blumenthal-Barby, who is
an ethicist philosopher whostudies nudging, and it's really
used ubiquitously. It's based ona book written by Richard Thaler
(02:13):
and Cass Sunstein, and it talksabout behavioral economics and
just the way things arepresented, the way things are
delivered, whether it's visuallyor verbally, that influences
people's decisions andbehaviors. So it's everywhere.
It's definitely within medicine.
Everywhere in the ICU, we do alot of high-stakes decision
making, big conversations. Andso that's really where the idea
(02:35):
of studying nudging came for me,in those care conferences, those
conversations with families,where we're going to say things,
they're going to be presented ina given order. And so there's
going to be some meaningattached to that, whether it's
on purpose or not. So that'sreally where it came from.
Joanna Hart (02:53):
For me, I think I'll add that nudging, as it's
applied to healthcare has, Ithink, most commonly been
thought of as either clinician-or patient-directed
interventions, if you will, thatare usually around flipping a
switch somewhere. So there aremany nudges that involve
(03:14):
clinician directed orders ordecision supports that are
really around what I call likeflipping a switch in the EHR,
where it changes the way thatordering clinicians see an order
set or a default. And so a veryclassic example of this might be
to change the default whenyou're ordering a prescription
(03:35):
from a list of ten things toseeing the generic option as the
default, because ordering ageneric saves money, and so in
that way, it sort of makes aclinician's life a little bit
easier as they're ordering it,and gets the clinician to do
something you want them to do,and they would probably choose
to do anyway. That is oftendifferent from how I think many
(03:58):
of us think about nudging whenit comes to communication. So
it's still the same concept asAliza sort of described, but
when we're studying it here,we're really thinking about
again, those individualcommunication, those individual
decision points that cliniciansare really facilitating for
(04:20):
families of patients or patientsthemselves in some
circumstances. And of course,those are very high-stakes in
the ICU, and those are a littlebit different nudges than many
people will think of as sort ofthe prototypical nudge within
health system.
Laura Miller-Smith (04:35):
I probably learned about the concept of
choice architecture and nudgingaround the same time that Aliza
did, being engaged in thebioethics certificate course at
Children's Mercy. The conceptreally resonated with me,
because for many years I hadrecognized that I made
consciously a lot of decisionsabout how I presented choices
(04:57):
within the ICU setting, both tofamilies, patients, if they had
the capacity to make decisionsfor themselves, but also to
colleagues whom I was trying toget on board with potential
changes to interventions or whatwe are offering some families.
Joanna Hart (05:14):
And I think Laura is right, and I think she's
alluding to but maybe not sayingexplicitly, so I'll say it
explicitly, but I think sheagrees with me, is that another
reason why the ICU environmentis so critical to understand
this, particularly in thecontext of communication between
clinicians and decision makers,is that the decisions that we're
(05:34):
talking about are also veryvalue sensitive decisions, so
there typically isn't sort of avery clear correct decision,
that most of the decisions thatwe make in the ICU are really
dependent on the values of thedecision maker, and that's a bit
different than, for example,nudging people to do colorectal
screening in a guidelineappropriate way. In this
(05:58):
context, clinicians have a lotof leeway to figure out what is
the quote-unquote "right answer"that we should be nudging or
influencing people to selectbased on what decision is value
aligned. And so it's helping toprovide an additional tool that
clinicians, if they're likeLaura, are aware that they're
using. The vast majority ofclinicians, I think, are not
(06:18):
aware or cognizant orspecifically choosing a choice
architecture or choice framing,or a nudge that is accounting
for both the influence of thatand the influence of that in a
particular direction, which mayor may not be a value aligned
choice, but that's, I thinkultimately, the goal of most
intensivist or pediatricpalliative care clinicians is
(06:39):
that they are trying to matchthe decisions that are actually
being made with the values ofthe person who's making the
decisions, or who they'rerepresenting as they make those
decisions.
Sarah Dabagh (06:50):
And I think one of the challenges that I see is, I
worry sometimes, especially withpeople who are not aware that
they are using nudging, that Isee clinicians nudging to align
with perhaps more their ownvalues than the actual
identified values of the family.
In your study, you identifiedtracheostomy as the most common
nudging, value laden kind ofdecision.
Laura Miller-Smith (07:13):
I think many of us in pediatric critical care
do see a significant variationin how saliency is used for
tracheostomy and some otherdecision making around different
diagnoses. This is one inparticular for me that I know
caused a significant amount ofmoral distress the last
intensive care unit where Iworked, because providers and
(07:35):
other team members working inpalliative care and social work
or pulmonology or ENT wouldcomment that there was
significant variation in howintensivists were depicting life
after tracheostomy for families,and how that was swaying parents
in their decision making, andcausing those individuals who
(07:56):
are not leading theconversations a significant
amount of moral distress becausethey felt like it was really
life or death decisions, and aprovider was molding those
decisions in a way that had hugeimpact on their families.
Joanna Hart (08:09):
I do think this discussion actually highlights a
really important point that it'sreally important for, I think,
listeners and clinicians torecognize that any type of
presentation will have aninfluence. And so there is no
such thing as neutral choicearchitecture, or a neutral way
of presenting information. Andwhat we found in our work, in a
(08:32):
variety of studies on the topic,is really that clinicians often
will initially have thistendency, and in casual
conversation, this comes up too,where neutrality is the goal,
and we should be sort of thisneutral party. And I think you
can have sort of an ethicaldebate on sort of what should
the role of a clinician shouldbe professionally, and is the
(08:53):
goal really neutrality? Which Idon't personally think it is.
And I think probably mostlisteners would recognize that
part of our role as whetherwe're an intensivist or in a
palliative care role, we arethere to guide and it's not just
about being a neutral party.
However, regardless of whetheror not you think neutrality is
the goal or not, any way thatyou're presenting choices,
(09:13):
options, medical decisions isgoing to have an influence, even
if you're trying to present itin a neutral way, let's say
you're presenting three options.
The order in which you presentthose three options is going to
have an influence. And sothinking about this is, as
others have said, you know, itis pervasive. It is something
(09:34):
that all clinicians are doing ona regular basis, whether or not
they are aware of it. And therecannot be neutral choice
architecture.
Aliza Olive (09:42):
And I think when we don't know about nudging and
we're just presenting things theway we're going to present them,
personal biases probably comeinto play a lot more. We all
have them, right? There's somelevel of disability bias, or
what we think this family shoulddo, or what I know I would do
for. My family if tracheostomywas on the table for a variety
(10:03):
of different reasons, and so ifyou're not aware of how you're
presenting the information,you're probably putting a lot of
personal bias into theconversation.
Daniel Eison (10:11):
I'm really glad you brought up bias, because as
you were talking about nudging,I was thinking a lot about the
conversations around implicitbias as something that everyone
has, is completely unavoidable,but because of that, it's
important to be aware of it andto think about the ways that
it's influencing the decisionsyou make and the decisions you
present and the way youcommunicate.
Laura Miller-Smith (10:31):
As a profession, we have to own our
significant role in choicearchitecture and the impact on
families, and have to invest ineducation on the role of our own
personal biases, how werecognize our biases, and then
how we bring that into careconferences or times more,
asking families and patients tomake decisions. That's one of
(10:53):
the exciting things to me aboutthis work and other work that is
being done on choicearchitecture, is that we're
getting to a place where we canreally hopefully demonstrate
that this is worth investing infor formal education, because
the consequences are huge ifthese conversations are held in
non deliberate ways. I alsothink that it behooves
(11:13):
leadership to monitor the impactof individual performance on
different decisions from kind oflike a quality lens, like
knowing that there may be somevariation in decision making
amongst your team, and trying tobe very transparent about
calling out what might bedriving some of that is
(11:33):
essential.
Daniel Eison (11:34):
I'm really glad you mentioned that, because, I
mean, we all have that (11:36):
I look at who the attending is in the
PICU or the NICU before I go tothe goals of care conversation,
because I'm like, "Well, I mean,this guy's on, so I know we're
not going to do a trach." Andthat's real.
Sarah Dabagh (11:47):
But I think I also hear and feel the tension
between, Joanna, what you said,which is, there's no such thing
as a nudge-free, completelyneutral conversation, and being
aware of how you're usingnudging in conversations, I see
a tension between what feelslike an appropriate amount of
nudging, if there is going to benudging, what feels like an
(12:08):
appropriate use. And then how doyou really give that feedback?
And how do people act on thatfeedback?
Joanna Hart (12:13):
We know that clinicians are not good at
predicting the result or type ofinfluence that choice
architecture has. We've doneempirical work on that,
clinicians sort of lackcompetency in choice
architecture. They're not taughtabout it. They generally learn
communication strategies likethat through what we call an
apprenticeship model, throughtraining environments, where
(12:35):
they sort of mimic what peoplearound them are doing, rather
than having a lot of influenceby formal education on
communication patterns,particularly about something
like choice architecture, whatwe call, for example, a default,
I would argue, is probably not atrue default in nudging and
choice architecture language,because it doesn't meet the
requirements for an ethicaldefault or an ethical type of
(12:59):
nudge using a default choice,because to do that, there are
certain things that have to bein place. The person has to know
that there is a decision sort ofat hand being presented to them,
which oftentimes cliniciansdon't make readily apparent.
There has to be an understandingof the alternative choices and
how to choose those alternativechoices. Oftentimes that's not
included in quote, unquote,default language that clinicians
(13:22):
are using. So if they saysomething like, now we're going
to start dialysis, even thoughthat's a value sensitive
decision, and we all maybe, asclinicians, recognize that
starting dialysis or putting ina tracheostomy or any number of
other interventions should be avalue sensitive decision. There
is not a clinical guideline thatsays this is the next thing that
you do, if it is not alignedwith the person's values or the
(13:44):
family's values, we recognizethat that's a value sensitive
choice, but the receivingpatient or family may not
recognize that that is a valuesensitive choice if it's
presented as a default in thatway. And so the advantage of
something like a yes, noquestion, which you know, we
might formally call a polarinterrogative, is that it allows
(14:05):
the family member to at leastreceive that as a decision.
They're at least presented witha decision. Default has been the
overwhelming sort of majority ofthe way that clinicians present
a lot of these value sensitivedecisions in the ICUs. So when
clinicians start to getoverwhelmed with this sort of
thing, I say, let's focus onthat.
Aliza Olive (14:21):
Joanna, can you give an example, using the
dialysis, of the proper way topresent that default?
Joanna Hart (14:28):
Yeah, sure. So let's say someone is-- a
clinician is saying, "Okay, ifthe renal function is not better
by tomorrow, we're going tostart dialysis." That is a value
sensitive decision. We'representing it as this is the
next step in a clinical pathway,instead of saying, is dialysis
aligned with this person or thisfamily's values for this
(14:49):
patient, right? And so insteadof presenting it as sort of that
default, we might instead say,"The renal function is not
improving. That leaves us withsome choices to make," right?
One choice would be dialysis.
Explain sort of the benefits ofdialysis. If you think it's a
recommendation, say this is whyit might be my recommendation.
"An alternative to dialysiswould be this, that, and the
(15:10):
other. It could be waitinglonger. Here's why. I don't
think that's a good choice tomake." It could be that we've
now reached a point where wehave another organ that's
failing. So if we choose not todo dialysis, then this is sort
of the alternative plan, andthat's where something like
palliative care comes into play.
Because oftentimes we findintensivists presenting this
(15:32):
sort of default for moreinterventions, this idea of sort
of clinical momentum, we just dothe next intervention that we
have, instead of presenting aviable alternative option that
might be something like comfortfocused care or de escalation of
care.
Aliza Olive (15:46):
I use default the opposite way I think a lot more,
and maybe it comes off more as arecommendation, but I'm very
personally sensitive to thedistress that families have in
end of life decision making inwriting papers and doing a lot
of literature reviews, I becamefamiliar with the statistics on
PTSD involved with saying thewords, we're ready to redirect
(16:06):
care. And so I tend to notuniversally, but use default in
those situations when it's veryclear that that's what the
family wants, and they justcan't and don't want to and are
not comfortable saying it,saying, Okay, our next steps can
be and then sort of describing,and then they can agree to it.
And I don't want this to comeoff that I'm taking kids off of
(16:28):
support without family'spermissions. Just trying to be
really sensitive to thedifficulty of saying those words
out loud for a lot of families.
Sarah Dabagh (16:36):
You're touching on something we talk a lot about in
palliative care, which is thatsometimes families really do
want a recommendation, andpresenting things as completely
neutral is actually verydistressing for families if they
want to feel like they have madethe right choice, the most
loving choice, the guided choicethat makes them the best parent.
I think again, it's that tensionbetween, you know, what is a
(16:57):
wanted nudge and what is ahelpful nudge in the bereavement
process of a family. And Laura,you use the word "everything,"
and I know you put it in airquotes which our listeners won't
be able to see, but even wordslike "everything," right and re
changing how we use those words,in a way, that's also nudging,
and that's something that we tryand do a lot in palliative care.
Joanna Hart (17:17):
Thanks, Sarah, you touched on, and Aliza to touched
on, something that is, I think,really important when we think
about nudging, or sort ofcommunication writ large, nudges
are an example of supporteddecision making and
communication, if done well.
This is where, and I think allof your listeners probably are
well attuned to this, ratherthan focusing on specific
(17:38):
interventions, but ratherunderstanding sort of, what are
the values, what are the sort ofmore broad outcomes that are
acceptable or unacceptable,rather than dialysis, yay or
nay, which is, you know, sort ofa nonsensical decision, and it's
really much more around whathappens after the dialysis, you
know, like, what are theimplications of starting
(17:59):
dialysis is the outcome alignedwith my values for how I want to
live as an individual, or how Iwant my child's life to be. If
we can understand those values,then it makes it easier for us
to decrease cognitive load orthe families making decisions
improve their support duringdecision making, but that relies
on us eliciting values first,which is, you know, fundamental
(18:24):
part of palliative care, Ithink.
Sarah Dabagh (18:27):
Ao, our last episode that just came out
included a call for more routinebioethics education in medical
education, specificallypalliative care education. And
now I feel the call again herefrom specific communication
based education, and I'mwondering what that would look
like in an ideal world based onboth your work and just the
(18:49):
general sort of knowledge thatwe have about how little
communication education peopleget formally.
Aliza Olive (18:54):
I'll go first, with the caveat that I am the most
junior clinician and juniorethicist in this group. I don't
do a lot in the way ofeducation, but I've found as a
newer attending and as a memberof our end of life committee and
trying to work with some of theinterests in fellow education
that sims have helped. It's nota formal communication
(19:17):
curriculum, and it's certainlynot designed to teach nudging,
but we do sort of separatepediatric critical care fellow
and then all pediatric fellowsims surrounding end of life
type conversations or difficultconversations, and it's been
very helpful.
Joanna Hart (19:35):
I agree, simulation is a great tool. I also think
that doing it in fellowship isprobably too late, because we've
habituated probably a lot of ourcommunication patterns by then,
and so moving that sort ofstrategy earlier and recognizing
that medical schools areoverwhelmed with what they have
to teach future clinicians, butrecognizing that communication
(19:56):
is such an important skill tohave. It's just as important as
procedural skills. It is just asimportant as pathophysiology.
Because this is human medicine;we have to interact with other
humans in order to do themedicine. And so recognizing how
important that is early, andintegrating that early, I think,
is paramount.
Sarah Dabagh (20:16):
The funny part is, I am starting to see some
communication education pop backup in pediatrics. But the way
I'm seeing it is in a decisionwe don't want to be a value
sensitive decision, but familiesthink is, which is vaccine
refusal. That's where I'm seeingit pop back up.
Aliza Olive (20:33):
The bad form of the default nudge is really good
there (20:35):
"We are going to give the six month vaccines today."
Daniel Eison (20:39):
Well and there are studies that show that that is
That's what I say.
the most effective thing, right?
Like, that just works if youjust make it the default.
Aliza Olive (20:45):
The bad default, right? Unethical default.
Daniel Eison (20:48):
So here's my tangential question
talked about the way thatclinicians nudge other
clinicians. We've talked aboutthe way that clinicians nudge
families. We've talked brieflyabout how administrators or EMR
creators nudge clinicians, butit must be a two way street.
Families and patients must nudgeus when they're talking to us.
(21:09):
Is that something that you guysthink about, is that something
that should enter this calculuswhen we're thinking about
nudging like the way that what apatient and family says impacts
the way we feel, the way wethink the decisions we make?
Joanna Hart (21:21):
I hadn't thought of that before in that specific
way, so I do think it probablyhappens. I think my general
take, however, is that healthsystems and clinicians as agents
of the health system aretypically in the position of
power whenever someone ishospitalized. We are the
gatekeeper for interventions. Wehave, in many ways, sort of
(21:44):
ultimate decision making power.
And I don't necessarily agreethat that's how the power
structure should be, or that weshould have health systems
oriented to exerting power overfamilies, but I do think that
while clinicians are undoubtedlyinfluenced by how patients and
family members presentthemselves and present
information. I think ultimatelywe still have the power, and
(22:05):
therefore we still have theresponsibility of using that
both informational power andaccess power appropriately and
responsibly.
Laura Miller-Smith (22:15):
I think it's important for doctors to
recognize when they're beingnudged and need to assure that
they are staying true to whatthey think best evidence is, and
that they're not being pushed todeviate from what they think
appropriate care is. And ifthere's a question about that,
have that conversation with thefamily.
Joanna Hart (22:36):
I think there also is an expectation, and this goes
back to what Laura said at thebeginning of our conversation
around this idea of hot versuscold states of thinking, and
clinicians, should I supposehave the ability to maintain a
more rational decision makingmindset. And I don't mean
(22:56):
rationality in the sense thatfamily members are irrational.
What I mean by that is, when wethink about sort of the cold,
less activated, less emotionallystressful thinking, clinicians
should be able to maintain thatsystem of thinking, where we are
less susceptible to heuristicsand shortcuts and so forth. And
of course, we are, to someextent, because all humans are
(23:18):
in any state. But when we thinkabout that, in contrast to
family members, who, as we said,you know, "Just save my baby,"
they are in an emotionallyheightened state. It is very,
very hard, and not even justemotionally heightened, but
they're sleep deprived. There islots of other stressors
happening in their life. Thereare, you know, noise stressors
and other foreign environments,and they're learning all these
(23:40):
new sort of people and systems,while they have this threat of
mortality to their loved one. Itis much harder for them to
transition from that sort ofhighly emotionally and stress
activated state of rapidthinking relying on shortcuts,
or those cognitive shortcutsthat we call heuristics, which
makes them more susceptible tothings like nudges, as opposed
(24:01):
to clinicians. So cliniciansshould be able to maintain that
resistance to those heuristicsthat allow them to do their
professional duties.
Sarah Dabagh (24:10):
I think a challenge there, and the
parallel question, I wonder, andI've heard it posed a couple of
times, is there such thing as atruly informed decision in
healthcare? There is this wealthof information that we hold,
let's say, as an ICU physician,that you hold about what life
might look like after a decisionor after a big medical change.
And we can't hand all thatinformation to the family at
(24:31):
once. It just doesn't fit in theroom. It just doesn't fit in a
grieving, stressed brain. Andthen we get to pick and choose
what information we present, andthat's part of the nudging. But
at the same time, what we hearfrom families is the information
that we hold as physicians,let's say, as an ICU physician,
is still also not the fullpicture, and that life at home
(24:51):
is part of that full picture,and that nobody really holds all
of it like it's just notpossible--unless there is an ICU
physician who has a medicallycomplex child at home, maybe
they have the closest--but it'simpossible to hold all that
information in any oneindividual body, whether or not
it's parent or ICU physician.
Aliza Olive (25:08):
I think congenital cardiac disease is a big place
where I personally see that theoutcomes are very variable, and
they're better than they used tobe, and they're good enough for
a lot of people, but there's alot of values laden decisions
there, and there's absolutely noway that the consent process
(25:28):
for, you know, a hypoplast cango over every possible thing
that can happen to that babythroughout the course,
especially with how variable thephysiology can be. And Tessie
October, at Children's National,did a study on decision regret
and tracheostomy placement,which is really interesting, and
I think delves into that a bitabout, you know, families don't
(25:51):
know what they're getting intowhen they agree to this. I had a
patient in fellowship where thefamily did a tracheostomy and
stayed for all of the trainingthat went into it, and went
home, and within a week, cameback for a palliative
decannulation, which was verymorally distressing to all of
us, but it wasn't what theythought it was going to be, and
they weren't comfortable withwhat they had chosen. And that's
(26:13):
what Tessie shows in her paper.
Laura Miller-Smith (26:14):
I tell my trainees all the time that
informed consent doesn't trulyexist, and it's a myth, and
please separate out thedifference between you getting a
signature on a piece of paperthat's a medico-legal issue,
versus feeling that you gave thefamily everything they needed to
make an informed decision. SoI'm pretty blatant with trainees
about that. The fact that it isa bit of a fantasy doesn't take
(26:35):
away the responsibility oftrying to convey as much
information as we possibly canto families, but do it with some
humility, and do it trying toget that clear understanding
that we can't predict everythingand everyone's experience is
different. I tell the familiesof the congenital heart disease
patients I take care of,especially the single ventricles
that their post op course, andfrankly, their lives is going to
(26:57):
be a bit of a roller coaster,but that roller coaster ride is
different for every single childand every single family. And I
wish, I wish I could tell themwhat it's going to look like
when the curves and the dips andall that will happen, but I
can't.
Joanna Hart (27:11):
I love that, Laura.
I study expectation accuracy inadult patients with chronic
illness, and I think that's thepart of Sarah's question that
was so hard for me, and I thinkyou both spoke to it very well,
is the idea of, no, it wasimpossible to have a truly
informed decision, becausenobody knows the future, and
that's what we all care about,is what will happen in the
future, and nobody can knowthat. That is unknowable
(27:33):
information. We can do our bestto approximate it or predict it,
or, as Laura said, give therange of what might happen. But
no, I mean, there's never atruly informed decision if we
think about the universe ofpossibilities. And I don't think
we should be striving for thateither, because, again, I think
that amount of information canbe overwhelming, and being
(27:53):
really thoughtful aboutinformation provision, I think
is an important part of our jobas clinicians.
Sarah Dabagh (27:59):
So here's a hard question. If we are not striving
for nudge-free conversations,and we are not striving for
truly informed consent, how canwe describe what it is we are
striving for in theseconversations?
Aliza Olive (28:13):
I think the best we can do is to help guide the
family with the tools that wehave to a decision that is in
line with their values. I agree.
That's sort of the point ofnudging. That's the way that it
should be used ethically.
Daniel Eison (28:35):
So Sarah, what are our take-homes from this
episode?
Sarah Dabagh (28:38):
I think when I sat down and thought about this one,
I thought about myself goinginto this recording with a sense
of looking for a morality innudging, and maybe coming in
with a negative frame for what Ithought nudging was in practice.
And I think I left with more ofa moral neutrality and more of a
thoughtfulness about the topic,and essentially a greater
(29:01):
awareness of this communicationtactic, more than a
black-and-white, good-badmorality, which is sort of what
I expected to come in ready totalk about. My take-home really
is that pure neutrality, whichis what you would get with the
removal of nudging, is notactually what we are going for
in communication.
Daniel Eison (29:18):
I felt like this conversation allows me to kind
of forgive myself in a way, orbe compassionate towards myself.
You know, like this is a thingthat just happens when two human
beings talk to each other; we'reconstantly nudging in some way,
and you can't escape it. So theimportant thing to do is be
aware of it, but also it's anudge, not a shove, right? It's
(29:40):
not as big and impactful andviolent as I perhaps thought of
Sarah Dabagh (29:46):
I like the idea of separating out shoving, because
it.
I think we've all been in familyconferences where we've seen
shoving in practice. And you'reright, there is a very
different... I don't even knowwhat word to use, there is a
very different air to a shoveversus a nudge. "Violent" is a
good word.
Daniel Eison (30:02):
It's funny that I'm using the word "violent,"
because I'm coming back tothings like Judith Butler
talking about communication, andhow we have to approach all
interpersonal communication withhumility, because it's always
imperfect and it's alwaysfallible, and so approaching it
with a degree of compassion forourselves and the other is
(30:23):
important.
Sarah Dabagh (30:24):
Humility, compassion and awareness in
conversation. Yeah, I thinkthose are great take-home points
from this episode.
Daniel Eison (30:33):
Thanks for listening. Our theme song was
written by Kevin MacLeod. Youcan follow us on BlueSky, where
our username ispedipal.bsky.social. You can
find the notes for this episodeand all the others on our
website, pedipal.org. If you'dlike to submit thoughts,
objections, or ideas for futureepisodes, please reach out
through the email on our site.
This has been PediPal. See younext month.
(30:54):
So I'll say, you know,"...podcast about all things
pediatric palliative care, theviews in this podcast are ours
alone..."
Sarah Dabagh (31:01):
"...symptom management, communication..."
And I can be like, "Dan, it'sinteresting you bring up
communication! I wonder if thatmight actually be something that
you would like to talk abouttoday." I don't know.
Daniel Eison (31:11):
Yeah, no, that's good. That's good. And then I
could say something like,"Sarah, it feels like you're
nudging me in a certaindirection for this episode."
Sarah Dabagh (31:18):
I do have an end in mind to the conversation,
which is not how we actually sayyou're supposed to have
conversations, but it's oftenhow we do in practice.
Daniel Eison (31:24):
"So why don't we hear from our guests who are
experts in nudging, who can tellus more about how this works."
Sarah Dabagh (31:28):
"Maybe you can offer a better intro, based on
actual nudging."
Daniel Eison (31:32):
"Hey, Sarah, it seems like you're nudging me
inexpertly. Like you don'treally know what nudging is.
Let's talk to the people who do!
Sarah Dabagh (31:39):
Let's bring on two people... yeah, exactly!
[laughter]
Hi, this is Sarah,
Daniel Eison (00:02):
and this is Dan,
Sarah Dabagh (00:03):
and we'd like to welcome you to PediPal,
Daniel Eison (00:07):
a podcast about all things pediatric palliative
care.
Sarah Dabagh (00:11):
The views in this podcast are ours alone and do
not represent our respectiveorganizations, nor do they
constitute medical advice.
Daniel Eison (00:18):
And this podcast really does cover all things
pediatric palliative care,symptom management, goals,
communication...
Sarah Dabagh (00:25):
I wonder if it might be helpful in this episode
to talk a little bit more aboutcommunication.
Daniel Eison (00:32):
Sarah, it seems like you're nudging me in a
certain direction.
Sarah Dabagh (00:35):
The actual concept of nudging is way more nuanced
than what we just attempted todo, very unsuccessfully. But I
wonder if we might introducethat as the topic for the
episode, and bring on somepeople who can talk about what
actual nudging looks like incommunication and how to use it
thoughtfully and how to be awareof it.
Aliza Olive (00:55):
Hi, I'm Aliza Olive. I'm a pediatric
intensivist at Cleveland Clinicchildren's in Cleveland, Ohio,
and I also study ethics andnudging.
Laura Miller-Smith (01:05):
I'm Laura Miller-Smith. I am also [a]
pediatric intensivist. I serveas the Chief of the Division of
Pediatric Critical Care Medicineand Medical Director of
Pediatric Cardiac Critical CareServices at Doernbecher
Children's Hospital, which ispart of Oregon Health and
Sciences University, and I havesome additional training in
bioethics.
Joanna Hart (01:25):
My name is Joanna Hart. I am an Assistant
Professor of Medicine andMedical Ethics and Health Policy
at the University ofPennsylvania. I am also an
intensivist. I work in the adultICUs as well as I am a general
adult pulmonologist as well.
Sarah Dabagh (01:41):
So I wonder if I can start with a question based
o (01:44):
In front of us, we have three intensivists. What about
intensive care lends itself mostto the study of nudging?
Aliza Olive (01:53):
I mean, nudging is very universal. It's everywhere.
I first learned about it from anethics webinar that John Lantos
did at Children's Mercy withJenny Blumenthal-Barby, who is
an ethicist philosopher whostudies nudging, and it's really
used ubiquitously. It's based ona book written by Richard Thaler
(02:13):
and Cass Sunstein, and it talksabout behavioral economics and
just the way things arepresented, the way things are
delivered, whether it's visuallyor verbally, that influences
people's decisions andbehaviors. So it's everywhere.
It's definitely within medicine.
Everywhere in the ICU, we do alot of high-stakes decision
making, big conversations. Andso that's really where the idea
(02:35):
of studying nudging came for me,in those care conferences, those
conversations with families,where we're going to say things,
they're going to be presented ina given order. And so there's
going to be some meaningattached to that, whether it's
on purpose or not. So that'sreally where it came from.
Joanna Hart (02:53):
For me, I think I'll add that nudging, as it's
applied to healthcare has, Ithink, most commonly been
thought of as either clinician-or patient-directed
interventions, if you will, thatare usually around flipping a
switch somewhere. So there aremany nudges that involve
(03:14):
clinician directed orders ordecision supports that are
really around what I call likeflipping a switch in the EHR,
where it changes the way thatordering clinicians see an order
set or a default. And so a veryclassic example of this might be
to change the default whenyou're ordering a prescription
(03:35):
from a list of ten things toseeing the generic option as the
default, because ordering ageneric saves money, and so in
that way, it sort of makes aclinician's life a little bit
easier as they're ordering it,and gets the clinician to do
something you want them to do,and they would probably choose
to do anyway. That is oftendifferent from how I think many
(03:58):
of us think about nudging whenit comes to communication. So
it's still the same concept asAliza sort of described, but
when we're studying it here,we're really thinking about
again, those individualcommunication, those individual
decision points that cliniciansare really facilitating for
(04:20):
families of patients or patientsthemselves in some
circumstances. And of course,those are very high-stakes in
the ICU, and those are a littlebit different nudges than many
people will think of as sort ofthe prototypical nudge within
health system.
Laura Miller-Smith (04:35):
I probably learned about the concept of
choice architecture and nudgingaround the same time that Aliza
did, being engaged in thebioethics certificate course at
Children's Mercy. The conceptreally resonated with me,
because for many years I hadrecognized that I made
consciously a lot of decisionsabout how I presented choices
(04:57):
within the ICU setting, both tofamilies, patients, if they had
the capacity to make decisionsfor themselves, but also to
colleagues whom I was trying toget on board with potential
changes to interventions or whatwe are offering some families.
Joanna Hart (05:14):
And I think Laura is right, and I think she's
alluding to but maybe not sayingexplicitly, so I'll say it
explicitly, but I think sheagrees with me, is that another
reason why the ICU environmentis so critical to understand
this, particularly in thecontext of communication between
clinicians and decision makers,is that the decisions that we're
(05:34):
talking about are also veryvalue sensitive decisions, so
there typically isn't sort of avery clear correct decision,
that most of the decisions thatwe make in the ICU are really
dependent on the values of thedecision maker, and that's a bit
different than, for example,nudging people to do colorectal
screening in a guidelineappropriate way. In this
(05:58):
context, clinicians have a lotof leeway to figure out what is
the quote-unquote "right answer"that we should be nudging or
influencing people to selectbased on what decision is value
aligned. And so it's helping toprovide an additional tool that
clinicians, if they're likeLaura, are aware that they're
using. The vast majority ofclinicians, I think, are not
(06:18):
aware or cognizant orspecifically choosing a choice
architecture or choice framing,or a nudge that is accounting
for both the influence of thatand the influence of that in a
particular direction, which mayor may not be a value aligned
choice, but that's, I thinkultimately, the goal of most
intensivist or pediatricpalliative care clinicians is
(06:39):
that they are trying to matchthe decisions that are actually
being made with the values ofthe person who's making the
decisions, or who they'rerepresenting as they make those
decisions.
Sarah Dabagh (06:50):
And I think one of the challenges that I see is, I
worry sometimes, especially withpeople who are not aware that
they are using nudging, that Isee clinicians nudging to align
with perhaps more their ownvalues than the actual
identified values of the family.
In your study, you identifiedtracheostomy as the most common
nudging, value laden kind ofdecision.
Laura Miller-Smith (07:13):
I think many of us in pediatric critical care
do see a significant variationin how saliency is used for
tracheostomy and some otherdecision making around different
diagnoses. This is one inparticular for me that I know
caused a significant amount ofmoral distress the last
intensive care unit where Iworked, because providers and
(07:35):
other team members working inpalliative care and social work
or pulmonology or ENT wouldcomment that there was
significant variation in howintensivists were depicting life
after tracheostomy for families,and how that was swaying parents
in their decision making, andcausing those individuals who
(07:56):
are not leading theconversations a significant
amount of moral distress becausethey felt like it was really
life or death decisions, and aprovider was molding those
decisions in a way that had hugeimpact on their families.
Joanna Hart (08:09):
I do think this discussion actually highlights a
really important point that it'sreally important for, I think,
listeners and clinicians torecognize that any type of
presentation will have aninfluence. And so there is no
such thing as neutral choicearchitecture, or a neutral way
of presenting information. Andwhat we found in our work, in a
(08:32):
variety of studies on the topic,is really that clinicians often
will initially have thistendency, and in casual
conversation, this comes up too,where neutrality is the goal,
and we should be sort of thisneutral party. And I think you
can have sort of an ethicaldebate on sort of what should
the role of a clinician shouldbe professionally, and is the
(08:53):
goal really neutrality? Which Idon't personally think it is.
And I think probably mostlisteners would recognize that
part of our role as whetherwe're an intensivist or in a
palliative care role, we arethere to guide and it's not just
about being a neutral party.
However, regardless of whetheror not you think neutrality is
the goal or not, any way thatyou're presenting choices,
(09:13):
options, medical decisions isgoing to have an influence, even
if you're trying to present itin a neutral way, let's say
you're presenting three options.
The order in which you presentthose three options is going to
have an influence. And sothinking about this is, as
others have said, you know, itis pervasive. It is something
(09:34):
that all clinicians are doing ona regular basis, whether or not
they are aware of it. And therecannot be neutral choice
architecture.
Aliza Olive (09:42):
And I think when we don't know about nudging and
we're just presenting things theway we're going to present them,
personal biases probably comeinto play a lot more. We all
have them, right? There's somelevel of disability bias, or
what we think this family shoulddo, or what I know I would do
for. My family if tracheostomywas on the table for a variety
(10:03):
of different reasons, and so ifyou're not aware of how you're
presenting the information,you're probably putting a lot of
personal bias into theconversation.
Daniel Eison (10:11):
I'm really glad you brought up bias, because as
you were talking about nudging,I was thinking a lot about the
conversations around implicitbias as something that everyone
has, is completely unavoidable,but because of that, it's
important to be aware of it andto think about the ways that
it's influencing the decisionsyou make and the decisions you
present and the way youcommunicate.
Laura Miller-Smith (10:31):
As a profession, we have to own our
significant role in choicearchitecture and the impact on
families, and have to invest ineducation on the role of our own
personal biases, how werecognize our biases, and then
how we bring that into careconferences or times more,
asking families and patients tomake decisions. That's one of
(10:53):
the exciting things to me aboutthis work and other work that is
being done on choicearchitecture, is that we're
getting to a place where we canreally hopefully demonstrate
that this is worth investing infor formal education, because
the consequences are huge ifthese conversations are held in
non deliberate ways. I alsothink that it behooves
(11:13):
leadership to monitor the impactof individual performance on
different decisions from kind oflike a quality lens, like
knowing that there may be somevariation in decision making
amongst your team, and trying tobe very transparent about
calling out what might bedriving some of that is
(11:33):
essential.
Daniel Eison (11:34):
I'm really glad you mentioned that, because, I
mean, we all have that (11:36):
I look at who the attending is in the
PICU or the NICU before I go tothe goals of care conversation,
because I'm like, "Well, I mean,this guy's on, so I know we're
not going to do a trach." Andthat's real.
Sarah Dabagh (11:47):
But I think I also hear and feel the tension
between, Joanna, what you said,which is, there's no such thing
as a nudge-free, completelyneutral conversation, and being
aware of how you're usingnudging in conversations, I see
a tension between what feelslike an appropriate amount of
nudging, if there is going to benudging, what feels like an
(12:08):
appropriate use. And then how doyou really give that feedback?
And how do people act on thatfeedback?
Joanna Hart (12:13):
We know that clinicians are not good at
predicting the result or type ofinfluence that choice
architecture has. We've doneempirical work on that,
clinicians sort of lackcompetency in choice
architecture. They're not taughtabout it. They generally learn
communication strategies likethat through what we call an
apprenticeship model, throughtraining environments, where
(12:35):
they sort of mimic what peoplearound them are doing, rather
than having a lot of influenceby formal education on
communication patterns,particularly about something
like choice architecture, whatwe call, for example, a default,
I would argue, is probably not atrue default in nudging and
choice architecture language,because it doesn't meet the
requirements for an ethicaldefault or an ethical type of
(12:59):
nudge using a default choice,because to do that, there are
certain things that have to bein place. The person has to know
that there is a decision sort ofat hand being presented to them,
which oftentimes cliniciansdon't make readily apparent.
There has to be an understandingof the alternative choices and
how to choose those alternativechoices. Oftentimes that's not
included in quote, unquote,default language that clinicians
(13:22):
are using. So if they saysomething like, now we're going
to start dialysis, even thoughthat's a value sensitive
decision, and we all maybe, asclinicians, recognize that
starting dialysis or putting ina tracheostomy or any number of
other interventions should be avalue sensitive decision. There
is not a clinical guideline thatsays this is the next thing that
you do, if it is not alignedwith the person's values or the
(13:44):
family's values, we recognizethat that's a value sensitive
choice, but the receivingpatient or family may not
recognize that that is a valuesensitive choice if it's
presented as a default in thatway. And so the advantage of
something like a yes, noquestion, which you know, we
might formally call a polarinterrogative, is that it allows
(14:05):
the family member to at leastreceive that as a decision.
They're at least presented witha decision. Default has been the
overwhelming sort of majority ofthe way that clinicians present
a lot of these value sensitivedecisions in the ICUs. So when
clinicians start to getoverwhelmed with this sort of
thing, I say, let's focus onthat.
Aliza Olive (14:21):
Joanna, can you give an example, using the
dialysis, of the proper way topresent that default?
Joanna Hart (14:28):
Yeah, sure. So let's say someone is-- a
clinician is saying, "Okay, ifthe renal function is not better
by tomorrow, we're going tostart dialysis." That is a value
sensitive decision. We'representing it as this is the
next step in a clinical pathway,instead of saying, is dialysis
aligned with this person or thisfamily's values for this
(14:49):
patient, right? And so insteadof presenting it as sort of that
default, we might instead say,"The renal function is not
improving. That leaves us withsome choices to make," right?
One choice would be dialysis.
Explain sort of the benefits ofdialysis. If you think it's a
recommendation, say this is whyit might be my recommendation.
"An alternative to dialysiswould be this, that, and the
(15:10):
other. It could be waitinglonger. Here's why. I don't
think that's a good choice tomake." It could be that we've
now reached a point where wehave another organ that's
failing. So if we choose not todo dialysis, then this is sort
of the alternative plan, andthat's where something like
palliative care comes into play.
Because oftentimes we findintensivists presenting this
(15:32):
sort of default for moreinterventions, this idea of sort
of clinical momentum, we just dothe next intervention that we
have, instead of presenting aviable alternative option that
might be something like comfortfocused care or de escalation of
care.
Aliza Olive (15:46):
I use default the opposite way I think a lot more,
and maybe it comes off more as arecommendation, but I'm very
personally sensitive to thedistress that families have in
end of life decision making inwriting papers and doing a lot
of literature reviews, I becamefamiliar with the statistics on
PTSD involved with saying thewords, we're ready to redirect
(16:06):
care. And so I tend to notuniversally, but use default in
those situations when it's veryclear that that's what the
family wants, and they justcan't and don't want to and are
not comfortable saying it,saying, Okay, our next steps can
be and then sort of describing,and then they can agree to it.
And I don't want this to comeoff that I'm taking kids off of
(16:28):
support without family'spermissions. Just trying to be
really sensitive to thedifficulty of saying those words
out loud for a lot of families.
Sarah Dabagh (16:36):
You're touching on something we talk a lot about in
palliative care, which is thatsometimes families really do
want a recommendation, andpresenting things as completely
neutral is actually verydistressing for families if they
want to feel like they have madethe right choice, the most
loving choice, the guided choicethat makes them the best parent.
I think again, it's that tensionbetween, you know, what is a
(16:57):
wanted nudge and what is ahelpful nudge in the bereavement
process of a family. And Laura,you use the word "everything,"
and I know you put it in airquotes which our listeners won't
be able to see, but even wordslike "everything," right and re
changing how we use those words,in a way, that's also nudging,
and that's something that we tryand do a lot in palliative care.
Joanna Hart (17:17):
Thanks, Sarah, you touched on, and Aliza to touched
on, something that is, I think,really important when we think
about nudging, or sort ofcommunication writ large, nudges
are an example of supporteddecision making and
communication, if done well.
This is where, and I think allof your listeners probably are
well attuned to this, ratherthan focusing on specific
(17:38):
interventions, but ratherunderstanding sort of, what are
the values, what are the sort ofmore broad outcomes that are
acceptable or unacceptable,rather than dialysis, yay or
nay, which is, you know, sort ofa nonsensical decision, and it's
really much more around whathappens after the dialysis, you
know, like, what are theimplications of starting
(17:59):
dialysis is the outcome alignedwith my values for how I want to
live as an individual, or how Iwant my child's life to be. If
we can understand those values,then it makes it easier for us
to decrease cognitive load orthe families making decisions
improve their support duringdecision making, but that relies
on us eliciting values first,which is, you know, fundamental
(18:24):
part of palliative care, Ithink.
Sarah Dabagh (18:27):
Ao, our last episode that just came out
included a call for more routinebioethics education in medical
education, specificallypalliative care education. And
now I feel the call again herefrom specific communication
based education, and I'mwondering what that would look
like in an ideal world based onboth your work and just the
(18:49):
general sort of knowledge thatwe have about how little
communication education peopleget formally.
Aliza Olive (18:54):
I'll go first, with the caveat that I am the most
junior clinician and juniorethicist in this group. I don't
do a lot in the way ofeducation, but I've found as a
newer attending and as a memberof our end of life committee and
trying to work with some of theinterests in fellow education
that sims have helped. It's nota formal communication
(19:17):
curriculum, and it's certainlynot designed to teach nudging,
but we do sort of separatepediatric critical care fellow
and then all pediatric fellowsims surrounding end of life
type conversations or difficultconversations, and it's been
very helpful.
Joanna Hart (19:35):
I agree, simulation is a great tool. I also think
that doing it in fellowship isprobably too late, because we've
habituated probably a lot of ourcommunication patterns by then,
and so moving that sort ofstrategy earlier and recognizing
that medical schools areoverwhelmed with what they have
to teach future clinicians, butrecognizing that communication
(19:56):
is such an important skill tohave. It's just as important as
procedural skills. It is just asimportant as pathophysiology.
Because this is human medicine;we have to interact with other
humans in order to do themedicine. And so recognizing how
important that is early, andintegrating that early, I think,
is paramount.
Sarah Dabagh (20:16):
The funny part is, I am starting to see some
communication education pop backup in pediatrics. But the way
I'm seeing it is in a decisionwe don't want to be a value
sensitive decision, but familiesthink is, which is vaccine
refusal. That's where I'm seeingit pop back up.
Aliza Olive (20:33):
The bad form of the default nudge is really good
there (20:35):
"We are going to give the six month vaccines today."
Daniel Eison (20:39):
Well and there are studies that show that that is
That's what I say.
the most effective thing, right?
Like, that just works if youjust make it the default.
Aliza Olive (20:45):
The bad default, right? Unethical default.
Daniel Eison (20:48):
So here's my tangential question
talked about the way thatclinicians nudge other
clinicians. We've talked aboutthe way that clinicians nudge
families. We've talked brieflyabout how administrators or EMR
creators nudge clinicians, butit must be a two way street.
Families and patients must nudgeus when they're talking to us.
(21:09):
Is that something that you guysthink about, is that something
that should enter this calculuswhen we're thinking about
nudging like the way that what apatient and family says impacts
the way we feel, the way wethink the decisions we make?
Joanna Hart (21:21):
I hadn't thought of that before in that specific
way, so I do think it probablyhappens. I think my general
take, however, is that healthsystems and clinicians as agents
of the health system aretypically in the position of
power whenever someone ishospitalized. We are the
gatekeeper for interventions. Wehave, in many ways, sort of
(21:44):
ultimate decision making power.
And I don't necessarily agreethat that's how the power
structure should be, or that weshould have health systems
oriented to exerting power overfamilies, but I do think that
while clinicians are undoubtedlyinfluenced by how patients and
family members presentthemselves and present
information. I think ultimatelywe still have the power, and
(22:05):
therefore we still have theresponsibility of using that
both informational power andaccess power appropriately and
responsibly.
Laura Miller-Smith (22:15):
I think it's important for doctors to
recognize when they're beingnudged and need to assure that
they are staying true to whatthey think best evidence is, and
that they're not being pushed todeviate from what they think
appropriate care is. And ifthere's a question about that,
have that conversation with thefamily.
Joanna Hart (22:36):
I think there also is an expectation, and this goes
back to what Laura said at thebeginning of our conversation
around this idea of hot versuscold states of thinking, and
clinicians, should I supposehave the ability to maintain a
more rational decision makingmindset. And I don't mean
(22:56):
rationality in the sense thatfamily members are irrational.
What I mean by that is, when wethink about sort of the cold,
less activated, less emotionallystressful thinking, clinicians
should be able to maintain thatsystem of thinking, where we are
less susceptible to heuristicsand shortcuts and so forth. And
of course, we are, to someextent, because all humans are
(23:18):
in any state. But when we thinkabout that, in contrast to
family members, who, as we said,you know, "Just save my baby,"
they are in an emotionallyheightened state. It is very,
very hard, and not even justemotionally heightened, but
they're sleep deprived. There islots of other stressors
happening in their life. Thereare, you know, noise stressors
and other foreign environments,and they're learning all these
(23:40):
new sort of people and systems,while they have this threat of
mortality to their loved one. Itis much harder for them to
transition from that sort ofhighly emotionally and stress
activated state of rapidthinking relying on shortcuts,
or those cognitive shortcutsthat we call heuristics, which
makes them more susceptible tothings like nudges, as opposed
(24:01):
to clinicians. So cliniciansshould be able to maintain that
resistance to those heuristicsthat allow them to do their
professional duties.
Sarah Dabagh (24:10):
I think a challenge there, and the
parallel question, I wonder, andI've heard it posed a couple of
times, is there such thing as atruly informed decision in
healthcare? There is this wealthof information that we hold,
let's say, as an ICU physician,that you hold about what life
might look like after a decisionor after a big medical change.
And we can't hand all thatinformation to the family at
(24:31):
once. It just doesn't fit in theroom. It just doesn't fit in a
grieving, stressed brain. Andthen we get to pick and choose
what information we present, andthat's part of the nudging. But
at the same time, what we hearfrom families is the information
that we hold as physicians,let's say, as an ICU physician,
is still also not the fullpicture, and that life at home
(24:51):
is part of that full picture,and that nobody really holds all
of it like it's just notpossible--unless there is an ICU
physician who has a medicallycomplex child at home, maybe
they have the closest--but it'simpossible to hold all that
information in any oneindividual body, whether or not
it's parent or ICU physician.
Aliza Olive (25:08):
I think congenital cardiac disease is a big place
where I personally see that theoutcomes are very variable, and
they're better than they used tobe, and they're good enough for
a lot of people, but there's alot of values laden decisions
there, and there's absolutely noway that the consent process
(25:28):
for, you know, a hypoplast cango over every possible thing
that can happen to that babythroughout the course,
especially with how variable thephysiology can be. And Tessie
October, at Children's National,did a study on decision regret
and tracheostomy placement,which is really interesting, and
I think delves into that a bitabout, you know, families don't
(25:51):
know what they're getting intowhen they agree to this. I had a
patient in fellowship where thefamily did a tracheostomy and
stayed for all of the trainingthat went into it, and went
home, and within a week, cameback for a palliative
decannulation, which was verymorally distressing to all of
us, but it wasn't what theythought it was going to be, and
they weren't comfortable withwhat they had chosen. And that's
(26:13):
what Tessie shows in her paper.
Laura Miller-Smith (26:14):
I tell my trainees all the time that
informed consent doesn't trulyexist, and it's a myth, and
please separate out thedifference between you getting a
signature on a piece of paperthat's a medico-legal issue,
versus feeling that you gave thefamily everything they needed to
make an informed decision. SoI'm pretty blatant with trainees
about that. The fact that it isa bit of a fantasy doesn't take
(26:35):
away the responsibility oftrying to convey as much
information as we possibly canto families, but do it with some
humility, and do it trying toget that clear understanding
that we can't predict everythingand everyone's experience is
different. I tell the familiesof the congenital heart disease
patients I take care of,especially the single ventricles
that their post op course, andfrankly, their lives is going to
(26:57):
be a bit of a roller coaster,but that roller coaster ride is
different for every single childand every single family. And I
wish, I wish I could tell themwhat it's going to look like
when the curves and the dips andall that will happen, but I
can't.
Joanna Hart (27:11):
I love that, Laura.
I study expectation accuracy inadult patients with chronic
illness, and I think that's thepart of Sarah's question that
was so hard for me, and I thinkyou both spoke to it very well,
is the idea of, no, it wasimpossible to have a truly
informed decision, becausenobody knows the future, and
that's what we all care about,is what will happen in the
future, and nobody can knowthat. That is unknowable
(27:33):
information. We can do our bestto approximate it or predict it,
or, as Laura said, give therange of what might happen. But
no, I mean, there's never atruly informed decision if we
think about the universe ofpossibilities. And I don't think
we should be striving for thateither, because, again, I think
that amount of information canbe overwhelming, and being
(27:53):
really thoughtful aboutinformation provision, I think
is an important part of our jobas clinicians.
Sarah Dabagh (27:59):
So here's a hard question. If we are not striving
for nudge-free conversations,and we are not striving for
truly informed consent, how canwe describe what it is we are
striving for in theseconversations?
Aliza Olive (28:13):
I think the best we can do is to help guide the
family with the tools that wehave to a decision that is in
line with their values. I agree.
That's sort of the point ofnudging. That's the way that it
should be used ethically.
Daniel Eison (28:35):
So Sarah, what are our take-homes from this
episode?
Sarah Dabagh (28:38):
I think when I sat down and thought about this one,
I thought about myself goinginto this recording with a sense
of looking for a morality innudging, and maybe coming in
with a negative frame for what Ithought nudging was in practice.
And I think I left with more ofa moral neutrality and more of a
thoughtfulness about the topic,and essentially a greater
(29:01):
awareness of this communicationtactic, more than a
black-and-white, good-badmorality, which is sort of what
I expected to come in ready totalk about. My take-home really
is that pure neutrality, whichis what you would get with the
removal of nudging, is notactually what we are going for
in communication.
Daniel Eison (29:18):
I felt like this conversation allows me to kind
of forgive myself in a way, orbe compassionate towards myself.
You know, like this is a thingthat just happens when two human
beings talk to each other; we'reconstantly nudging in some way,
and you can't escape it. So theimportant thing to do is be
aware of it, but also it's anudge, not a shove, right? It's
(29:40):
not as big and impactful andviolent as I perhaps thought of
Sarah Dabagh (29:46):
I like the idea of separating out shoving, because
it.
I think we've all been in familyconferences where we've seen
shoving in practice. And you'reright, there is a very
different... I don't even knowwhat word to use, there is a
very different air to a shoveversus a nudge. "Violent" is a
good word.
Daniel Eison (30:02):
It's funny that I'm using the word "violent,"
because I'm coming back tothings like Judith Butler
talking about communication, andhow we have to approach all
interpersonal communication withhumility, because it's always
imperfect and it's alwaysfallible, and so approaching it
with a degree of compassion forourselves and the other is
(30:23):
important.
Sarah Dabagh (30:24):
Humility, compassion and awareness in
conversation. Yeah, I thinkthose are great take-home points
from this episode.
Daniel Eison (30:33):
Thanks for listening. Our theme song was
written by Kevin MacLeod. Youcan follow us on BlueSky, where
our username ispedipal.bsky.social. You can
find the notes for this episodeand all the others on our
website, pedipal.org. If you'dlike to submit thoughts,
objections, or ideas for futureepisodes, please reach out
through the email on our site.
This has been PediPal. See younext month.
(30:54):
So I'll say, you know,"...podcast about all things
pediatric palliative care, theviews in this podcast are ours
alone..."
Sarah Dabagh (31:01):
"...symptom management, communication..."
And I can be like, "Dan, it'sinteresting you bring up
communication! I wonder if thatmight actually be something that
you would like to talk abouttoday." I don't know.
Daniel Eison (31:11):
Yeah, no, that's good. That's good. And then I
could say something like,"Sarah, it feels like you're
nudging me in a certaindirection for this episode."
Sarah Dabagh (31:18):
I do have an end in mind to the conversation,
which is not how we actually sayyou're supposed to have
conversations, but it's oftenhow we do in practice.
Daniel Eison (31:24):
"So why don't we hear from our guests who are
experts in nudging, who can tellus more about how this works."
Sarah Dabagh (31:28):
"Maybe you can offer a better intro, based on
actual nudging."
Daniel Eison (31:32):
"Hey, Sarah, it seems like you're nudging me
inexpertly. Like you don'treally know what nudging is.
Let's talk to the people who do!
Sarah Dabagh (31:39):
Let's bring on two people... yeah, exactly!
[laughter]
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