Nudging to Improve End-of-life Care Planning


Several years ago, Richard Thaler and Cassie Sunstein published a book with a simple title and an apparently simple premise. The book was called Nudge: Improving Decisions About Health, Wealth, and Happiness. The premise was we can improve how we make decisions with small generally painless nudges. The work popularized leading edge neuroscience that postulates a division of labor in the human brain, between the fast System 1, that has a complete catalog of our entire experience and makes snap decisions to protect us from foolish mistakes, and the slow System 2, which uses a deliberative approach to problems that weighs evidence, does calculations, questions assumptions and so on, to make a reasoned decision that ultimately will also protect us from our impulsive selves. (Did I say simple? It is really, it’s just a little wordy to describe.)

How about a story? A study looked at what happens when you put a pound of M&Ms in a single large bowl, versus putting a 1/4 pound in four small bowls. The study showed people ate a significantly larger number of M&Ms from the large bowl, because System 1 assessed the large bowl as the default serving size. So they tested people to see if simply unpacking a large package of some food into smaller packages would reduce calorie intake, and of course, it did! There are dozens of other examples of how simple deliberate modifications in things like default options, serving dishes, daily routines, and so on, can make significant changes in outcome, without any apparent change in behavior required. You still reach for the M&Ms in the bowl, but without even meaning to, you do it less often and take fewer when you do. The smaller bowl is the nudge towards a more reasonable choice.

The idea is to take deliberate steps (using System 2 for the thinking part) to set up defaults that take advantage of the way System 1 makes decisions. So, what does this have to do with death and end-of-life care and all that?

That’s what I wanted to find out! Last week, I hosted #DWDchat and we focused on nudging and how our choices about end-of-life care are subtly influenced by our System 1 or System 2 decision making. When someone brings up the subject of advanced directives, most of us leave the driving to System 1, which says, more or less automatically, that yeah, we know what we want, and we leave it at that. If we could engage System 2, we might think more deeply about the issue and realize that our loved ones can’t know how we feel if we don’t tell them.

After a few tweets to explain the idea and give examples, I asked if tweetchatters were familiar with the idea, if they’d encountered it, and whether they could think of ways we could use nudging to help people start The Conversation about end-of-life choices and advanced directives.

The discussion was lively and thoughtful. Some worried there were already a lot of distractions and strong emotions when facing end-of-life situations. Most took the view that doctors and healthcare professionals might use some kind of nudge, such as providing a pamphlet or informational form, to ease into the conversation, and others saw that as too intrusive or unlikely to have a positive impact unless done extremely carefully. Some pointed out the time to do this is long before such decisions need to be put into action, when we’re not faced with immediate choices. In the end, I think we all agreed at least on this: any action taken to initiate a conversation like this, whether direct or indirect, requires great tact and awareness of the emotional state of the patient and caregivers.

So when it comes to starting The Conversation, what simple deliberate nudges can we implement to make having the talk the default rather than the exception? Please tell us in the comments section below!

Some additional reading about nudging:

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