Decision making in perceived devastating brain injury: a call to explore the impact of cognitive biases

Rohaut, Benjamin; Claassen, Jan

doi:10.1016/j.bja.2017.11.007

Cited by 49 publications

(34 citation statements)

References 21 publications

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“…Bias that may result in underuse of life support in severe stroke patients include erroneous prognostic estimates [33][34][35], misunderstanding patient's values and expectation [36], and undervaluing the future patient's health state (disability paradox) [29,37]. The in uence of cognitive bias in the decision-making process must also be acknowledged, and may be as important as patient factors [38]. Inappropriate prognostic pessimism and premature limitations of life support de ne the mechanism by which self-ful lling prophecies occur [39].…”

Section: Discussionmentioning

confidence: 99%

Withholding and Withdrawal of Life Support in Mechanically Ventilated Stroke Patients

Montmollin

Schwebel

Dupuis

et al. 2020

Preprint

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Background. The determinants of decisions to limit life support (withholding or withdrawal) in ventilated stroke patients have been poorly investigated.Methods. In a prospective multicenter observational cohort (2005-2016), we evaluated limitation of life support in ventilated stroke patients compared to a non-brain-injured population and identified factors associated with such decisions in stroke patients using Fine and Gray competing risk models.Results. We identified 373 stroke patients (ischemic, n=167 (45%); hemorrhagic, n=206 (55%)), and 5683 non-brain-injured patients. Decisions to limit life support were taken in 41% of ischemic stroke cases (vs. non-brain-injured patients, sHR 3.59 [95% CI 2.78-4.65]) and in 33% of hemorrhagic stroke cases (vs. non-brain-injured patients, sHR 3.9 [95% CI 2.97-5.11]). Time from ICU admission to the first limitation was longer in ischemic than in hemorrhagic stroke (5 [3 - 9] vs 2 [1 - 6] days, p<0.01). Limitation of life support preceded ICU death in 70% of ischemic strokes and 45% of hemorrhagic strokes (p<0.01). Life support limitation in ischemic stroke was associated with a vertebrobasilar location (vs. anterior circulation, sHR, 1.61 [95% CI 1.01 - 2.59]) and in hemorrhagic stroke, it was associated with an age>70 years (2.29 [1.43 - 3.69]), a Glasgow score<8 (2.15 [1.08 - 4.3]) and a lower non-neurologic admission SOFA score (per point, 0.89 [0.82 - 0.97]).Conclusions. In ventilated stroke patients, decisions to limit life support are more than 3 times more frequent than in non-brain injured patients, with different timing and associated risk factors between ischemic and hemorrhagic strokes.

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Section: Discussionmentioning

confidence: 99%

Withholding and Withdrawal of Life Support in Mechanically Ventilated Stroke Patients

Montmollin

Schwebel

Dupuis

et al. 2020

Preprint

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“…6,7 Our anchoring cognitive bias (ie, the misassumption that we maintained) was that the patient was underresuscitated from the OR. [7][8][9][10] We committed a search satisficing error (ie, we prematurely stopped considering other diagnostic possibilities) when we did not pursue additional testing for bleeding when the patient's hemoglobin failed to appropriately increase with PRBC transfusion. 7,8,10 We assumed that the patient was adequately resuscitated when his hemoglobin finally increased 10 g/L with the fourth PRBC transfusion and, mistakenly, did not perform CT imaging to rule out retroperitoneal bleeding.…”

Section: Discussionmentioning

confidence: 99%

“…As a result of our confirmation bias (ie, our focus on data that supported the original diagnosis), we undervalued evidence for occult retroperitoneal bleeding, such as multiple transfusions, low CVP, ongoing norepinephrine requirement, and normal abdominal examination. [7][8][9][10] Strategies to mitigate these cognitive errors include awareness of potential cognitive biases, metacognition (ie, thinking about the decision-making process), and deliberate reconsideration of objective facts. [7][8][9][10][11] Our case demonstrates the difficulty of diagnosing postoperative hypotension caused by occult retroperitoneal bleeding and retroperitoneal hematoma formation underneath a watertight retroperitoneal closure.…”

Section: Discussionmentioning

confidence: 99%

Retroperitoneal Hematoma Following Elective Abdominal Aortic Aneurysm Repair: A Case Report

Holowachuk

Oreopoulos

2020

A&A Practice

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Retroperitoneal hematoma formation following elective open abdominal aortic aneurysm (AAA) repair may be occult. We report a case of recurrent hypotensive episodes in the postanesthesia care unit (PACU) that were temporarily treated successfully with fluid, blood products, and vasopressors. At reoperation, active bleeding was excluded; however, upon reopening the bovine pericardial patch closure of the retroperitoneum, hematoma between the aneurysmal sac and inferior vena cava (IVC) had caused IVC compression. Evacuation of the hematoma rapidly restored venous return and hemodynamics. This report describes a case of retroperitoneal hematoma formation and highlights challenges associated with diagnosing bleeding in this compartment.

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“…Moreover, interaction in small groups could have actually had a positive effect since pools of small groups insights’ have been shown to outperform the overall judgment of the group [26]. This kind of tool might be less prone to individual subjective bias that can be observed during decision making under high degree of uncertainty such as assessment of DoC patients [27]. Caregivers could have also been biased by the perception of patients’ relatives, although it is commonly acknowledged that relatives frequently lack objectivity (in both directions) in such dramatic situations [12].…”

Section: Discussionmentioning

confidence: 99%

“DoC-feeling”: a new behavioural tool to help diagnose the Minimally Conscious State

Hermann

Goudard

Courcoux

et al. 2018

Preprint

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ObjectivesThe clinical distinction between vegetative state/unresponsive wakefulness syndrome (UWS) and minimally conscious state (MCS) is a key step to elaborate a prognosis and formulate an appropriate medical plan for any patient suffering from disorders of consciousness (DoC). However, this assessment is often challenging and may require specialized expertise. In this study, we hypothesized that pooling subjective reports of the level of consciousness of a given patient across several nursing staff members can be used to clinically detect MCS.Setting and ParticipantsPatients referred for consciousness assessment were prospectively screened. MCS (target condition) was defined according to the best Coma Recovery Scale-Revised score (CRS-R) obtained from expert physicians (reference standard). “DoC-feeling” score consisted in the median value of multiple ratings of patient’s behavior observation pooled from multiple staff members during a week of hospitalisation (index test). Individual ratings were collected at the end of each shift using a 100mm visual analog scale, blinded from the reference standard. Diagnostic accuracy was evaluated using area under the receiver operating characteristic curve (AUC), sensitivity and specificity metrics.Results692 ratings performed by 83 nursing staff members were collected from 47 patients. Twenty patients were in a UWS and 27 in a MCS. DoC-feeling scores obtained by pooling all individual ratings obtained for a given patient were significantly greater in MCS than in UWS patients (59.2 mm [IQR: 27.3-77.3] vs. 7.2 mm [IQR: 2.4-11.4]; p<0.001) yielding an AUC of 0.92 (95%CI: 0.84-0.99).ConclusionsDoC-feeling capitalizes on the expertise of nursing staff to evaluate patients’ consciousness. Together with the CRS-R as well as with brain imaging, DoC-feeling might improve diagnostic and prognostic accuracy of DoC patients.Strengths and limitations of this studyWe designed a new behavioural tool called “DoC-feeling” to help face the clinical challenge of the detection of Minimally Conscious State in patients suffering from disorders of consciousness (DoC)“DoC-feeling score” quantifies nursing staff’s subjective perception of patient’s consciousness by pooling multiple assessments obtained from multiple caregivers (“wisdom of the crowds”)This score which requires no particular training showed a very good accuracy when compared to the gold standard (repeated expert clinical assessment using the Coma Recovery Scale – Revised (CRS-R))A validation in a separate cohort would help to determine its place in consciousness assessmentThis score should be tested not only against the CRS-R but also against brain-imaging techniques to test for its capacity to detect covert signs of consciousness

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Decision making in perceived devastating brain injury: a call to explore the impact of cognitive biases

Cited by 49 publications

References 21 publications

Withholding and Withdrawal of Life Support in Mechanically Ventilated Stroke Patients

Withholding and Withdrawal of Life Support in Mechanically Ventilated Stroke Patients

Retroperitoneal Hematoma Following Elective Abdominal Aortic Aneurysm Repair: A Case Report

“DoC-feeling”: a new behavioural tool to help diagnose the Minimally Conscious State

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