Challenging cognitive biases in the intensive care unit

By Harleen Kaur Johal & Christopher Danbury

Unsurprisingly, the intensive care unit (ICU) is an “intense” environment, for staff, patients, and their families. These busy, 24-hour units provide care for the most unwell patients in a hospital. As many of these patients are incapacitated, due to the effects of their illness or sedation, decisions must often be made in their best interests. This decision-making process is led by the consultant intensivist with input from the ICU team and those close to the patient. This inclusive approach is taken to ensure a comprehensive assessment of the patient’s best interests is made. However, these parties may not always agree, and conflict can develop when there is contention about where the best interests of the patient lie. For instance, a patient’s family may favour continuation of life-sustaining treatment, in contrast to the consultant intensivist, who is reluctant to provide aggressive treatment that they consider to be inappropriate. But conflicts do not necessarily occur between the family and ICU team. The disagreement may be within the ICU team or amongst those close to the patient, or between the ICU team and those close to the patient.

Conflict has a lasting impact on both the family and the ICU team. The family of a critically unwell patient may feel isolated and unsupported by the ICU team, during a time when they are in equal need of care. Within the ICU itself, conflict is thought to contribute to the high rate of ‘burnout’ and considerable moral distress encountered by healthcare professionals. Given its harmful effects, a deeper understanding of why conflict occurs is necessary, alongside potential strategies to resolve it.

Kahneman and Tversky’s work in the fields of cognitive psychology and behavioural economics may offer some insight. They argue that humans do not naturally make logical or rational choices but instead, the decision-making process is framed by cognitive biases. This is secondary to a tendency to over-simplify decisions by basing their understanding of the decision on their previous experiences, which are probably unrepresentative sets of observations. Hence, Kahneman suggests that the mind primarily deals with ‘known knowns’, which are its observations. It rarely considers ‘known unknowns’, which are recognised as relevant but do not factor significantly into the decision-making process, due to a lack of experiential information. The human mind is therefore oblivious to ‘unknown unknowns’. i.e. occurrences, of which the mind has no prior knowledge or experience. Following on from this, unpicking misalignments and identifying biases in the family’s and clinician’s decision-making processes may offer strategies to resolve these conflicts.

One such bias is ‘confirmation bias’: the tendency to search for information in such a way that confirms pre-existing beliefs. This bias is thought to have a stronger effect in the context of emotionally-charged issues. In the ICU, families may display a tendency to seek information that validates their belief that their relative has a good chance of survival. Similarly, healthcare professionals possess their own biases, and Kahneman and Tversky had previously acknowledged the practical implications of their work on clinical judgement. Of particular interest in this context, is ‘the bias blind spot’. This cognitive bias entails recognising the impact of biases on the judgment of others, but failing to see the impact of biases on one’s own judgment. Reflection and introspection have become an essential feature of clinical culture, and cognitive biases may be a component of clinical decision-making, of which clinicians have little awareness.

As conflict may unfortunately be inevitable, a deeper understanding of why conflict occurs may allow us to recognise and challenge our own cognitive biases, as well as those of others. In doing so, we may be able to prevent the escalation of conflict when it does occur.


Paper title:

Conflict before the courtroom: challenging cognitive biases in critical decision-making


Harleen Kaur Johal1 & Christopher Danbury2,3


1) Centre for Ethics in Medicine, University of Bristol, Bristol, UK
2) Adult Intensive Care Unit, Royal Berkshire NHS Foundation Trust, Reading, UK
3) School of Law, University of Reading, Reading, UK

Competing interests:

None declared.

Social media accounts of post authors:

@harleen_johal and @medic_mediator

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