Table 4 Definitions and descriptions of Clinical Decision-Making in geriatric emergency medicine
From: Conceptualizations of clinical decision-making: a scoping review in geriatric emergency medicine
ID | Definition | CDM in GEM | Summary/themes |
|---|---|---|---|
13 | “In making [treatment decisions, physicians] consider the disease, patient circumstances, and patient perceptions, as well as other factors. […] physicians engage in a large amount of mental processing [and] are often constrained by bounded rationality and satisficing...” (P154–155) | They found that the amount of treatment alternatives when encountering geriatric patients could alter decision-making. However, experience and the opportunity to supervise students reduced the risk of cognitive biases. | BIASES and DIAGNOSTICS Complexity in geriatric patients increases risk of bias, as it requires a larger amount of mental processing. REFLECTION Reflection helps. |
29 | ““Clinical experience” consists of several components: [e.g.] accumulated knowledge [and] skill in collecting historical data... Knowledge is accumulated more or less [as a] data bank. Biases of availability, representativeness, and anchoring have been shown to be relevant, but it is not clear how much they detract from the value of “experience”.” (P163) | investigating coronary heart disease (CHD), which is a common geriatric medical condition, but does not address geriatric patients directly | BIASES Address a common geriatric disease. EXPERIENCE They found no effect of experience on decision making competencies in differential diagnosis of common conditions. |
30 | “… the ways in which the cognitive processes were used to solve the clinical problem had an enormous impact on the diagnostic error. The overreliance on the use of patterns was crucial.” (P1280) | Not addressed directly, other than the case description | DIAGNOSTIC ERROR: Overreliance on pattern-use in complex patients can increase diagnostic errors, and that errors are more likely to occur “...when clinical patterns run counter to expectations... [and that this] had a major role in causing the errors, rather than factors related to procedures or organization.” |
32 | Mental Shortcuts: “Cognitive errors are particularly frequent when the clinical decision-making process heavily relies on heuristics. These could be defined as ‘mental shortcuts’ …” (P2030). “Cognitive faculties deserve particular attention, as they are the bases of the clinical decision-making process … human abilities are limited and both gathering and retrieving information are inaccurate processes...” | Cognitive errors with geriatric patients because of failed heuristics and complexity with patients. Aiming to show how technology use can be a reliant tool. | HEURISTICS Complexity in patients cause errors in cognition, as it is guided by heuristics. Especially geriatric patients are complex REFLECTION “...continuous reappraisal and critical interpretation of all information are the mainstay of both the diagnosing process and the conscious use of heuristics.” |
35 | Builds upon several theories but concludes by formulating a model, which “...recognizes the salience of individual cognition, as well as acknowledging that the knowledge and experience that guides that cognition is constructed through social interaction and organizational context.” (P161) | “A number of studies internationally have identified that pain is often substantially undertreated or untreated in geriatric patients … There are particular issues with the management of pain for older patients in acute hospital settings.” (P153) “It moves beyond a model of pain recognition, assessment and management as being located within a sequential linear decision making framework, recognizing the importance of collaborative, co-constructed knowledge which develops time.” (P161) | COMMUNICATION It points to the importance of communication and patient involvement, especially with geriatric patients, in correct diagnostic assessment of pain. |
26 | Describes decision making as ‘mental models’ which is further described as thought processes. It refers to former studies describing “… how norms might affect hospital-based physician’s decision-making heuristics, case perceptions, and the consequential diagnosis and treatment...” (P345) | patient shared decision making/preferences and other situational characteristics influencing acute care decisions: Describing the physician’s mental models when encountering a terminally ill elderly patient and their decision to intubate or not and compare these with the appropriateness of the treatment plan (if the decision was a mistake or not). Treatment mistakes were related to patients reluctant to disclose mistakes to the physician and the physician reluctant to disclose uncertainty to patients. | DIAGNOSTIC ERROR Transparency between physician and patient affects risk of errors, but this was not compared between elderly and non-elderly patients. BIASES However, it was described that this transparency might be influenced by heuristics and social factors. |
33 | “… judgements are not based solely on a static phenomonen of pre-existing patient criteria, but come to be revised as the performance is played out throughout the interaction.” (P2449) | based on a geriatric clinical encounter, the authors note that “… the nurse possesses prior expectations as to how someone of this age would appear.” (P1446) | HEURISTICS Appraisal of the patient’s symptoms is guided by clinician heuristics, which result in over- or under-triage with geriatric patients |
17 | “Heuristics are mental shortcuts that often produce valid judgements but can lead to errors in atypical or rare events. Because they reflect natural processes, heuristics are not easily, or even productively, replaced.” (P9204) | No mention | HEURISTICS and EDUCATION They found that a narrative simulation game intervention reduced undertriage, by ‘recalibrating’ heuristics. This could be a result of the emotional part of a narrative approach, making them reflect upon their triage in another way. They did not, however, compare non-geriatric with geriatric patients, as all cases were geriatric, based on the assumption about common heuristics with elderly patients. |
19 | “The decision to order physical restraint is complex, influenced not only by the uncertainty resulting from lack of clinical guidelines and evidence, but also by organizational and situational factors and patient-specific variables. […] judgements are based on interactions between the environment and the individual.” (P1280) | “… lack of education regarding acute care geriatric medicine and physical restraint …” + “Presence of dementia increased the likelihood of having a restraint order 1.7 times. Very old age (85 years) resulted in a trend for lower likelihood …” (P1285) | EDUCATION A lack of geriatric knowledge in acute settings increases risk of treatment errors COMMUNICATION The presence of dementia increased risk of treatment errors due to poorer communication opportunities and increased complexity HEURISTIC Older age decreased risk of treatment errors as a result of frailty heuristics, which was unique for geriatric patients. |
34 | “Clinicians also use heuristic observation of objective factors and application of scientific data, but also ‘tacit’ knowledge based on acquired expertise and pattern recognition” (P116) | “The most important determinants of perception of inappropriate CPR were objective criteria such as … older age …” (P116) | HEURISTICS Older age increased risk of treatment errors in regards to CPR |
24 | “Clinical judgement can be defines as “an interpretation or conclusion about a patient’s needs, concerns, or health problems, and/or the decision to take action (or not), use or modify standard approaches, or improvise new ones as deemed appropriate by the patient’s response” [11]. It is complex and requires a flexible ability to recognise prominent aspects of an undefined clinical situation interpret their meaning and respond appropriately. It relates to the experience of individual clinicians.” (P5) | older patients are more often at high risk and current identification of these often relies on clinical judgement, which is flawed. Because of the complexity of these patients, a need for standardized, routine measurements are needed, in order to aid the identification of older patients at high risk of poor healthcare outcomes or admission to hospital. | TREATMENT ERRORS Elders are complex and therefore unaided clinical judgement alone is not enough. We need standardized measures to decrease risk of errors due to implicit flaws in cognition |
46 | “… at the individual level, we observed that ED physicians had the autonomy in decision-making [but] were also uncertainty avoidant when presented with equivocal results … At the ED-specific organisational level, this study highlighted the deep-rooted culture of the ED of practicing evidence-based Medicine [and how s] enior physicians were sources of information and role models … [P]hysician’s decision to prescribe antibiotics was [also] influenced at the community level by patient expectations” (P5–6) | Majority of the participants reported a lower threshold in prescribing antibiotics for elderly patients, especially those with comorbidities or were immunocompromised. The main reasons were to prevent any potential deterioration of the patient’s illness or occurrence of secondary bacterial infections. The availability of social support for elderly patients was also taken into consideration | HEURISTICS Heuristics about elderly patient’s frailty influenced prescription and the underuse of antibiotics amongst elderly patients UNCERTAINTY Physicians were uncertainty avoidant and tended to overprescribe antibiotics when faced with uncertainty |
52 | “Framing bias occurs when people make a decision based on the way the information is presented, as opposed to just on the facts themselves.” (P589) | No mention | BIAS How a case is framed has significant effect on differential diagnosis DIAGNOSTIC ERRORS These biases lead to diagnostic errors. However, it is still unclear is debiasing can prevent this |