Sarah Dabagh: 0:01

Hi, this is Sarah,

Daniel Eison: 0:02

and this is Dan,

Sarah Dabagh: 0:03

and we'd like to welcome you to PediPal,

Daniel Eison: 0:07

a podcast about all things pediatric palliative care.

Sarah Dabagh: 0:11

The views in this podcast are ours alone and do not represent our respective organizations, nor do they constitute medical advice.

Daniel Eison: 0:18

And this podcast really does cover all things pediatric palliative care, symptom management, goals, communication...

Sarah Dabagh: 0:25

I wonder if it might be helpful in this episode to talk a little bit more about communication.

Daniel Eison: 0:32

Sarah, it seems like you're nudging me in a certain direction.

Sarah Dabagh: 0:35

The actual concept of nudging is way more nuanced than what we just attempted to do, very unsuccessfully. But I wonder if we might introduce that as the topic for the episode, and bring on some people who can talk about what actual nudging looks like in communication and how to use it thoughtfully and how to be aware of it.

Aliza Olive: 0:55

Hi, I'm Aliza Olive. I'm a pediatric intensivist at Cleveland Clinic children's in Cleveland, Ohio, and I also study ethics and nudging.

Laura Miller-Smith: 1:05

I'm Laura Miller-Smith. I am also [a] pediatric intensivist. I serve as the Chief of the Division of Pediatric Critical Care Medicine and Medical Director of Pediatric Cardiac Critical Care Services at Doernbecher Children's Hospital, which is part of Oregon Health and Sciences University, and I have some additional training in bioethics.

Joanna Hart: 1:25

My name is Joanna Hart. I am an Assistant Professor of Medicine and Medical Ethics and Health Policy at the University of Pennsylvania. I am also an intensivist. I work in the adult ICUs as well as I am a general adult pulmonologist as well.

Sarah Dabagh: 1:41

So I wonder if I can start with a question based

on your introductions, which is: 1:44

In front of us, we have three intensivists. What about intensive care lends itself most to the study of nudging?

Aliza Olive: 1:53

I mean, nudging is very universal. It's everywhere. I first learned about it from an ethics webinar that John Lantos did at Children's Mercy with Jenny Blumenthal-Barby, who is an ethicist philosopher who studies nudging, and it's really used ubiquitously. It's based on a book written by Richard Thaler and Cass Sunstein, and it talks about behavioral economics and just the way things are presented, the way things are delivered, whether it's visually or verbally, that influences people's decisions and behaviors. So it's everywhere. It's definitely within medicine. Everywhere in the ICU, we do a lot of high-stakes decision making, big conversations. And so that's really where the idea 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 in a given order. And so there's going to be some meaning attached to that, whether it's on purpose or not. So that's really where it came from.

Joanna Hart: 2:53

For me, I think I'll add that nudging, as it's applied to healthcare has, I think, most commonly been thought of as either clinician- or patient-directed interventions, if you will, that are usually around flipping a switch somewhere. So there are many nudges that involve clinician directed orders or decision supports that are really around what I call like flipping a switch in the EHR, where it changes the way that ordering clinicians see an order set or a default. And so a very classic example of this might be to change the default when you're ordering a prescription from a list of ten things to seeing the generic option as the default, because ordering a generic saves money, and so in that way, it sort of makes a clinician'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 often different from how I think many of us think about nudging when it comes to communication. So it's still the same concept as Aliza sort of described, but when we're studying it here, we're really thinking about again, those individual communication, those individual decision points that clinicians are really facilitating for families of patients or patients themselves in some circumstances. And of course, those are very high-stakes in the ICU, and those are a little bit different nudges than many people will think of as sort of the prototypical nudge within health system.

Laura Miller-Smith: 4:35

I probably learned about the concept of choice architecture and nudging around the same time that Aliza did, being engaged in the bioethics certificate course at Children's Mercy. The concept really resonated with me, because for many years I had recognized that I made consciously a lot of decisions about how I presented choices within the ICU setting, both to families, patients, if they had the capacity to make decisions for themselves, but also to colleagues whom I was trying to get on board with potential changes to interventions or what we are offering some families.

Joanna Hart: 5:14

And I think Laura is right, and I think she's alluding to but maybe not saying explicitly, so I'll say it explicitly, but I think she agrees with me, is that another reason why the ICU environment is so critical to understand this, particularly in the context of communication between clinicians and decision makers, is that the decisions that we're talking about are also very value sensitive decisions, so there typically isn't sort of a very clear correct decision, that most of the decisions that we make in the ICU are really dependent on the values of the decision maker, and that's a bit different than, for example, nudging people to do colorectal screening in a guideline appropriate way. In this context, clinicians have a lot of leeway to figure out what is the quote-unquote "right answer" that we should be nudging or influencing people to select based on what decision is value aligned. And so it's helping to provide an additional tool that clinicians, if they're like Laura, are aware that they're using. The vast majority of clinicians, I think, are not aware or cognizant or specifically choosing a choice architecture or choice framing, or a nudge that is accounting for both the influence of that and the influence of that in a particular direction, which may or may not be a value aligned choice, but that's, I think ultimately, the goal of most intensivist or pediatric palliative care clinicians is that they are trying to match the decisions that are actually being made with the values of the person who's making the decisions, or who they're representing as they make those decisions.

Sarah Dabagh: 6:50

And I think one of the challenges that I see is, I worry sometimes, especially with people who are not aware that they are using nudging, that I see clinicians nudging to align with perhaps more their own values than the actual identified values of the family. In your study, you identified tracheostomy as the most common nudging, value laden kind of decision.

Laura Miller-Smith: 7:13

I think many of us in pediatric critical care do see a significant variation in how saliency is used for tracheostomy and some other decision making around different diagnoses. This is one in particular for me that I know caused a significant amount of moral distress the last intensive care unit where I worked, because providers and other team members working in palliative care and social work or pulmonology or ENT would comment that there was significant variation in how intensivists were depicting life after tracheostomy for families, and how that was swaying parents in their decision making, and causing those individuals who are not leading the conversations a significant amount of moral distress because they felt like it was really life or death decisions, and a provider was molding those decisions in a way that had huge impact on their families.

Joanna Hart: 8:09

I do think this discussion actually highlights a really important point that it's really important for, I think, listeners and clinicians to recognize that any type of presentation will have an influence. And so there is no such thing as neutral choice architecture, or a neutral way of presenting information. And what we found in our work, in a variety of studies on the topic, is really that clinicians often will initially have this tendency, and in casual conversation, this comes up too, where neutrality is the goal, and we should be sort of this neutral party. And I think you can have sort of an ethical debate on sort of what should the role of a clinician should be professionally, and is the goal really neutrality? Which I don't personally think it is. And I think probably most listeners would recognize that part of our role as whether we're an intensivist or in a palliative care role, we are there to guide and it's not just about being a neutral party. However, regardless of whether or not you think neutrality is the goal or not, any way that you're presenting choices, options, medical decisions is going to have an influence, even if you're trying to present it in a neutral way, let's say you're presenting three options. The order in which you present those three options is going to have an influence. And so thinking about this is, as others have said, you know, it is pervasive. It is something that all clinicians are doing on a regular basis, whether or not they are aware of it. And there cannot be neutral choice architecture.

Aliza Olive: 9:42

And I think when we don't know about nudging and we're just presenting things the way we're going to present them, personal biases probably come into play a lot more. We all have them, right? There's some level of disability bias, or what we think this family should do, or what I know I would do for. My family if tracheostomy was on the table for a variety of different reasons, and so if you're not aware of how you're presenting the information, you're probably putting a lot of personal bias into the conversation.

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 implicit bias as something that everyone has, is completely unavoidable, but because of that, it's important to be aware of it and to think about the ways that it's influencing the decisions you make and the decisions you present and the way you communicate.

Laura Miller-Smith: 10:31

As a profession, we have to own our significant role in choice architecture and the impact on families, and have to invest in education on the role of our own personal biases, how we recognize our biases, and then how we bring that into care conferences or times more, asking families and patients to make decisions. That's one of the exciting things to me about this work and other work that is being done on choice architecture, is that we're getting to a place where we can really hopefully demonstrate that this is worth investing in for formal education, because the consequences are huge if these conversations are held in non deliberate ways. I also think that it behooves leadership to monitor the impact of individual performance on different decisions from kind of like a quality lens, like knowing that there may be some variation in decision making amongst your team, and trying to be very transparent about calling out what might be driving some of that is 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 to the 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." And that'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, completely neutral conversation, and being aware of how you're using nudging in conversations, I see a tension between what feels like an appropriate amount of nudging, if there is going to be nudging, what feels like an appropriate use. And then how do you really give that feedback? And how do people act on that feedback?

Joanna Hart: 12:13

We know that clinicians are not good at predicting the result or type of influence that choice architecture has. We've done empirical work on that, clinicians sort of lack competency in choice architecture. They're not taught about it. They generally learn communication strategies like that through what we call an apprenticeship model, through training environments, where they sort of mimic what people around them are doing, rather than having a lot of influence by formal education on communication patterns, particularly about something like choice architecture, what we call, for example, a default, I would argue, is probably not a true default in nudging and choice architecture language, because it doesn't meet the requirements for an ethical default or an ethical type of nudge using a default choice, because to do that, there are certain things that have to be in place. The person has to know that there is a decision sort of at hand being presented to them, which oftentimes clinicians don't make readily apparent. There has to be an understanding of the alternative choices and how to choose those alternative choices. Oftentimes that's not included in quote, unquote, default language that clinicians are using. So if they say something like, now we're going to start dialysis, even though that's a value sensitive decision, and we all maybe, as clinicians, recognize that starting dialysis or putting in a tracheostomy or any number of other interventions should be a value sensitive decision. There is not a clinical guideline that says this is the next thing that you do, if it is not aligned with the person's values or the family's values, we recognize that that's a value sensitive choice, but the receiving patient or family may not recognize that that is a value sensitive choice if it's presented as a default in that way. And so the advantage of something like a yes, no question, which you know, we might formally call a polar interrogative, is that it allows the family member to at least receive that as a decision. They're at least presented with a decision. Default has been the overwhelming sort of majority of the way that clinicians present a lot of these value sensitive decisions in the ICUs. So when clinicians start to get overwhelmed with this sort of thing, I say, let's focus on that.

Aliza Olive: 14:21

Joanna, can you give an example, using the dialysis, of the proper way to present that default?

Joanna Hart: 14:28

Yeah, sure. So let's say someone is-- a clinician is saying, "Okay, if the renal function is not better by tomorrow, we're going to start dialysis." That is a value sensitive decision. We're presenting it as this is the next step in a clinical pathway, instead of saying, is dialysis aligned with this person or this family's values for this patient, right? And so instead of presenting it as sort of that default, we might instead say,"The renal function is not improving. That leaves us with some choices to make," right? One choice would be dialysis. Explain sort of the benefits of dialysis. If you think it's a recommendation, say this is why it might be my recommendation."An alternative to dialysis would be this, that, and the other. It could be waiting longer. Here's why. I don't think that's a good choice to make." It could be that we've now reached a point where we have another organ that's failing. So if we choose not to do dialysis, then this is sort of the alternative plan, and that's where something like palliative care comes into play. Because oftentimes we find intensivists presenting this sort of default for more interventions, this idea of sort of clinical momentum, we just do the next intervention that we have, instead of presenting a viable alternative option that might be something like comfort focused 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 a recommendation, but I'm very personally sensitive to the distress that families have in end of life decision making in writing papers and doing a lot of literature reviews, I became familiar with the statistics on PTSD involved with saying the words, we're ready to redirect care. And so I tend to not universally, but use default in those situations when it's very clear that that's what the family wants, and they just can'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 come off that I'm taking kids off of support without family's permissions. Just trying to be really sensitive to the difficulty 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 that sometimes families really do want a recommendation, and presenting things as completely neutral is actually very distressing for families if they want to feel like they have made the right choice, the most loving choice, the guided choice that makes them the best parent. I think again, it's that tension between, you know, what is a wanted nudge and what is a helpful nudge in the bereavement process of a family. And Laura, you use the word "everything," and I know you put it in air quotes which our listeners won't be able to see, but even words like "everything," right and re changing how we use those words, in a way, that's also nudging, and that's something that we try and 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 of communication writ large, nudges are an example of supported decision making and communication, if done well. This is where, and I think all of your listeners probably are well attuned to this, rather than focusing on specific interventions, but rather understanding sort of, what are the values, what are the sort of more broad outcomes that are acceptable or unacceptable, rather than dialysis, yay or nay, which is, you know, sort of a nonsensical decision, and it's really much more around what happens after the dialysis, you know, like, what are the implications of starting dialysis is the outcome aligned with my values for how I want to live as an individual, or how I want my child's life to be. If we can understand those values, then it makes it easier for us to decrease cognitive load or the families making decisions improve their support during decision making, but that relies on us eliciting values first, which is, you know, fundamental part of palliative care, I think.

Sarah Dabagh: 18:27

Ao, our last episode that just came out included a call for more routine bioethics education in medical education, specifically palliative care education. And now I feel the call again here from specific communication based education, and I'm wondering what that would look like in an ideal world based on both your work and just the general sort of knowledge that we have about how little communication education people get formally.

Aliza Olive: 18:54

I'll go first, with the caveat that I am the most junior clinician and junior ethicist in this group. I don't do a lot in the way of education, but I've found as a newer attending and as a member of our end of life committee and trying to work with some of the interests in fellow education that sims have helped. It's not a formal communication curriculum, and it's certainly not designed to teach nudging, but we do sort of separate pediatric critical care fellow and then all pediatric fellow sims surrounding end of life type conversations or difficult conversations, 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 is probably too late, because we've habituated probably a lot of our communication patterns by then, and so moving that sort of strategy earlier and recognizing that medical schools are overwhelmed with what they have to teach future clinicians, but recognizing that communication is such an important skill to have. It's just as important as procedural skills. It is just as important as pathophysiology. Because this is human medicine; we have to interact with other humans in order to do the medicine. And so recognizing how important that is early, and integrating that early, I think, is paramount.

Sarah Dabagh: 20:16

The funny part is, I am starting to see some communication education pop back up in pediatrics. But the way I'm seeing it is in a decision we don't want to be a value sensitive decision, but families think is, which is vaccine refusal. That's where I'm seeing it 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 you just make it the default.

Aliza Olive: 20:45

The bad default, right? Unethical default.

Daniel Eison: 20:48

So here's my tangential question: We've talked about the way that clinicians nudge other clinicians. We've talked about the way that clinicians nudge families. We've talked briefly about how administrators or EMR creators nudge clinicians, but it must be a two way street. Families and patients must nudge us when they're talking to us. Is that something that you guys think about, is that something that should enter this calculus when we're thinking about nudging like the way that what a patient and family says impacts the way we feel, the way we think the decisions we make?

Joanna Hart: 21:21

I hadn't thought of that before in that specific way, so I do think it probably happens. I think my general take, however, is that health systems and clinicians as agents of the health system are typically in the position of power whenever someone is hospitalized. We are the gatekeeper for interventions. We have, in many ways, sort of ultimate decision making power. And I don't necessarily agree that that's how the power structure should be, or that we should have health systems oriented to exerting power over families, but I do think that while clinicians are undoubtedly influenced by how patients and family members present themselves and present information. I think ultimately we still have the power, and therefore we still have the responsibility of using that both informational power and access power appropriately and responsibly.

Laura Miller-Smith: 22:15

I think it's important for doctors to recognize when they're being nudged and need to assure that they are staying true to what they think best evidence is, and that they're not being pushed to deviate from what they think appropriate care is. And if there's a question about that, have that conversation with the family.

Joanna Hart: 22:36

I think there also is an expectation, and this goes back to what Laura said at the beginning of our conversation around this idea of hot versus cold states of thinking, and clinicians, should I suppose have the ability to maintain a more rational decision making mindset. And I don't mean rationality in the sense that family members are irrational. What I mean by that is, when we think about sort of the cold, less activated, less emotionally stressful thinking, clinicians should be able to maintain that system of thinking, where we are less susceptible to heuristics and shortcuts and so forth. And of course, we are, to some extent, because all humans are in any state. But when we think about that, in contrast to family members, who, as we said, you know, "Just save my baby," they are in an emotionally heightened state. It is very, very hard, and not even just emotionally heightened, but they're sleep deprived. There is lots of other stressors happening in their life. There are, you know, noise stressors and other foreign environments, and they're learning all these new sort of people and systems, while they have this threat of mortality to their loved one. It is much harder for them to transition from that sort of highly emotionally and stress activated state of rapid thinking relying on shortcuts, or those cognitive shortcuts that we call heuristics, which makes them more susceptible to things like nudges, as opposed to clinicians. So clinicians should be able to maintain that resistance to those heuristics that allow them to do their professional duties.

Sarah Dabagh: 24:10

I think a challenge there, and the parallel question, I wonder, and I've heard it posed a couple of times, is there such thing as a truly informed decision in healthcare? There is this wealth of information that we hold, let's say, as an ICU physician, that you hold about what life might look like after a decision or after a big medical change. And we can't hand all that information to the family at once. It just doesn't fit in the room. It just doesn't fit in a grieving, stressed brain. And then we get to pick and choose what information we present, and that's part of the nudging. But at the same time, what we hear from families is the information that we hold as physicians, let's say, as an ICU physician, is still also not the full picture, and that life at home is part of that full picture, and that nobody really holds all of it like it's just not possible--unless there is an ICU physician who has a medically complex child at home, maybe they have the closest--but it's impossible to hold all that information in any one individual 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 the outcomes are very variable, and they're better than they used to be, and they're good enough for a lot of people, but there's a lot of values laden decisions there, and there's absolutely no way that the consent process for, you know, a hypoplast can go over every possible thing that can happen to that baby throughout the course, especially with how variable the physiology 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 bit about, you know, families don't know what they're getting into when they agree to this. I had a patient in fellowship where the family did a tracheostomy and stayed for all of the training that went into it, and went home, and within a week, came back for a palliative decannulation, which was very morally distressing to all of us, but it wasn't what they thought it was going to be, and they weren't comfortable with what they had chosen. And that's what Tessie shows in her paper.

Laura Miller-Smith: 26:14

I tell my trainees all the time that informed consent doesn't truly exist, and it's a myth, and please separate out the difference between you getting a signature on a piece of paper that's a medico-legal issue, versus feeling that you gave the family everything they needed to make an informed decision. So I'm pretty blatant with trainees about that. The fact that it is a bit of a fantasy doesn't take away the responsibility of trying to convey as much information as we possibly can to families, but do it with some humility, and do it trying to get that clear understanding that we can't predict everything and everyone's experience is different. I tell the families of the congenital heart disease patients I take care of, especially the single ventricles that their post op course, and frankly, their lives is going to be a bit of a roller coaster, but that roller coaster ride is different for every single child and every single family. And I wish, I wish I could tell them what it's going to look like when the curves and the dips and all that will happen, but I can't.

Joanna Hart: 27:11

I love that, Laura. I study expectation accuracy in adult patients with chronic illness, and I think that's the part of Sarah's question that was so hard for me, and I think you both spoke to it very well, is the idea of, no, it was impossible to have a truly informed decision, because nobody knows the future, and that's what we all care about, is what will happen in the future, and nobody can know that. That is unknowable information. We can do our best to approximate it or predict it, or, as Laura said, give the range of what might happen. But no, I mean, there's never a truly informed decision if we think about the universe of possibilities. And I don't think we should be striving for that either, because, again, I think that amount of information can be overwhelming, and being really thoughtful about information provision, I think is an important part of our job as 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 can we describe what it is we are striving for in these conversations?

Aliza Olive: 28:13

I think the best we can do is to help guide the family with the tools that we have to a decision that is in line with their values. I agree. That's sort of the point of nudging. 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 going into this recording with a sense of looking for a morality in nudging, and maybe coming in with a negative frame for what I thought nudging was in practice. And I think I left with more of a moral neutrality and more of a thoughtfulness about the topic, and essentially a greater awareness of this communication tactic, more than a black-and-white, good-bad morality, which is sort of what I expected to come in ready to talk about. My take-home really is that pure neutrality, which is what you would get with the removal of nudging, is not actually 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, or be compassionate towards myself. You know, like this is a thing that just happens when two human beings talk to each other; we're constantly nudging in some way, and you can't escape it. So the important thing to do is be aware of it, but also it's a nudge, not a shove, right? It's not as big and impactful and violent 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 family conferences where we've seen shoving in practice. And you're right, there is a very different... I don't even know what word to use, there is a very different air to a shove versus 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 to things like Judith Butler talking about communication, and how we have to approach all interpersonal communication with humility, because it's always imperfect and it's always fallible, and so approaching it with a degree of compassion for ourselves and the other is important.

Sarah Dabagh: 30:24

Humility, compassion and awareness in conversation. Yeah, I think those are great take-home points from this episode.

Daniel Eison: 30:33

Thanks for listening. Our theme song was written by Kevin MacLeod. You can follow us on BlueSky, where our username is pedipal.bsky.social. You can find the notes for this episode and all the others on our website, pedipal.org. If you'd like to submit thoughts, objections, or ideas for future episodes, please reach out through the email on our site. This has been PediPal. See you next month. So I'll say, you know,"...podcast about all things pediatric palliative care, the views in this podcast are ours alone..."

Sarah Dabagh: 31:01

"...symptom management, communication..." And I can be like, "Dan, it's interesting you bring up communication! I wonder if that might actually be something that you would like to talk about today." 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 certain direction for this episode."

Sarah Dabagh: 31:18

I do have an end in mind to the conversation, which is not how we actually say you're supposed to have conversations, but it's often how we do in practice.

Daniel Eison: 31:24

"So why don't we hear from our guests who are experts in nudging, who can tell us 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't really 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]