Nudges for Prognosis and Comfort Care in the ICU: Kate Courtright, Scott Halpern, & Jaspal Singh

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GeriPal - A Geriatrics and Palliative Medicine Podcast 48 min 3 speakers 8 chapters transcribed 9 hours ago

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What is a “nudge” and how does it differ from “sludge” in clinical decision‑making?

Eric Widera 0:00

Welcome to the JerryPow podcast. This is Eric Widera.

Alex Smith 0:03

This is Alex Smith. And Alex, who

Eric Widera 0:05

do we have with us today?

Alex Smith 0:06

We are delighted to welcome back returning guest Scott Halpern, who is a pulmonary critical care physician and newly minted palliative medicine physician. And researcher and director of the Pair Center at the University of Pennsylvania. Pair stands for Palliative and Advanced Illness Research Center. Scott, welcome back to the Jerry Powell podcast.

Scott Halpern 0:28

Always great to be with you guys.

Alex Smith 0:30

And we're delighted to welcome back Kate Courtwright, who is also a pulmonary critical care and palliative care physician and researcher and core faculty at the Paris Center at the University of Pennsylvania. Kate, welcome back to JerryPal.

Kate Courtright 0:42

Thank you for having me again.

Alex Smith 0:44

And we're delighted to welcome Jaspaul Singh, who is a pulmonary critical care and sleep medicine physician who practices at Atrium Health and the Wake Forest University School of Medicine. Just Baal, welcome to the JerryPow podcast.

Jaspal Singh 0:59

Very happy to be here. Thank you for having me.

Eric Widera 1:01

So we got a good topic today. We're gonna be talking about a JAMA IM paper that just came out not too long ago. A nudging clinicians promote serious illness communication for critical ill patients. We've done a podcast already on nudging. Oof, what was it? The nudging podcast. We've done I feel like a couple. A couple of uh at least we had Scott and Kate talk about uh um a nudge on default palliative care. We also had a podcast. We have one

Alex Smith 1:25

with Jenny Blumenthal Barbie and Scott about what are nudges in general.

Eric Widera 1:33

We'll have links to that in our podcast notes. Um but before we dive into this topic Is it just ball, do you have a song request for Alex?

Jaspal Singh 1:45

Well I thought we'd uh requested Imagine by John Lennon.

Eric Widera 1:49

Why did you choose Imagine by John Lennon?

Jaspal Singh 1:52

Well, it's such a nice song about compassion, kindness, and the idea of us thinking of a world where the right things happen consistently all the time, and that's the culture. And which is what we're trying to accomplish with these types of nudges.

Alex Smith 2:08

Great. I love it. And we could all use a little John Lennon imagine right now. Here's a bit.

2:22

Imagine there's no country. It isn't hard to do. Nothing to kill or die for. And no religion to Imagine all the people. Living life in peace. You who you may say I'm a dreamer. But I'm not the only one. I hope someday you'll join us. And the word will be his one. Thank

Alex Smith 3:30

you, Alex. Thank you for that choice, Jess Paul. Needed.

Why did the researchers design a four‑arm ICU trial with prognosis and comfort‑care prompts?

Alex Smith 3:35

Thank you.

Eric Widera 3:35

So let's jump into this. I feel like nudges and behavioral economics, it's so hot right now. Like there have been a lot of trials. Uh there was just a couple out on like one was on polypharmacy using behavioral economics. Another one was on uh decreasing low value care that was published also in J I think Jemma IM. Um, before we talk about what you did in this study, maybe Scott, I'm gonna turn to you. Can you give me a reminder what a nudge is? Sure. I think it's Oh, Alex just hit

Alex Smith 4:10

me. Maybe that was an elbow. Sorry. Go ahead, Scott. Right.

Scott Halpern 4:18

Uh well. If you don't like this response, you can't hit me, so that's good. Um I think it's good to place nudges in context so. There are a lot of policy levelers at the disposal of any party that's trying to influence behaviors or outcomes. At one end of the spectrum you can provide decision makers with information. That doesn't work very well in most contexts. At the other end of the spectrum is you can totally remove certain options. So you could think about, you know, formularies at the hospitals we all practice on. I can't prescribe certain drugs. I'm just not allowed to. And and that works really well. Uh but it Can be seen as constraining the autonomy of the decision makers. Behavioral economics sort of operates in the middle of those two poles.

Scott Halpern 5:13

And can be defined as Any feature Of the environment in which a choice is being made or in which or or the way a choice is being framed that can foreseeably influence the probability that a specific choice is the one that's made. Without removing any choices or materially changing the incentives.

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Chapters

8 chapters

1 What is a “nudge” and how does it differ from “sludge” in clinical decision‑making? 0:00–3:35 2 Why did the researchers design a four‑arm ICU trial with prognosis and comfort‑care prompts? 3:35–8:25 3 How did the EHR prompts (prognosis vs. comfort‑care nudges) affect hospital length of stay? 8:25–13:59 4 What secondary outcomes showed improvement with the comfort‑care nudge (e.g., hospice enrollment, early comfort orders)? 13:59–19:47 5 Why did the prognosis‑focused nudge fail to move any clinical endpoints? 19:47–26:16 6 Is an EHR prompt considered a nudge or sludge, and what are the implications for alert fatigue? 26:16–33:39 7 How can health systems implement low‑cost nudges at scale without harming workflow? 33:39–40:07 8 What are the next steps for research and practice in using behavioral economics to improve ICU palliative care? 40:07–48:25

Speakers

3 identified

Eric Widera 7 min Alex Smith 5 min Bruno Satin

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Topics in this episode

Alex Smith 2 University of Pennsylvania 1 Eric Widera 2 John Lennon 1 Elizabeth Chung 1 Harry Hahn 1 Susan Nelson 1 Carol Heyman 1 Asher Edwards 1 JerryPow podcast 1 Sharon Brangman 1 JAMA Internal Medicine 1

Source

Recorded15 May 2025

Publisherrss.libsyn.com ↗

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Show notes

Our main focus today was on nudging critical care clinicians to consider a more palliative approach to care. Our guests are all trained in critical care: Kate Courtright, Scott Halpern, and Jaspal Singh. Kate and Scott have additional training in palliative medicine. To start. we review: What is a nudge? Also called behavioral interventions, heuristics, and cognitive biases. Prior podcasts on the ethics of nudging, and a different trial conducted by Kate and Scott in which the default for hospitalized seriously ill patients was to receive a palliative care consult. What is sludge? I'd never heard the term, perhaps outside of Eric's pejorative reference to my coffee after adding copious creamers, flavoring, and sweeteners. Sludge is apparently when you create barriers or extra work for someone. For example, putting the healthy food at the back of the grocery store is sludge; making an applicant for health insurance climb the flight of stairs to the office - weeding out those less fit - is also sludge. Prior-auth forms? Sludge. Examples of nudges, some based in health care, others in coffee. This specific study, published in JAMA Internal Medicine, was conducted in 17 ICUs in North Carolina. Many were community hospitals. Participants were critically ill and intubated. Clinicians were randomized to 4 groups: Usual care Prognosis nudge - EHR prompt asking, do you think your patient will be alive in 6 months? This is called a focusing effect Comfort care nudge - EHR prompt asking if they'd offered comfort-focused care. This is called accountable justification - an appeal to standards of care for critically ill patients endorsed by multiple professional societies. Both the prognosis and comfort care nudge. A few key points of discussion: Is an EHR prompt a nudge or sludge? The intervention was a negative study for the primary outcome, hospital length of stay. Why? The prognosis nudge did nothing. What to make of that? Would you think an EHR nudge to consider prognosis might move the needle, at least on some outcomes? The nudge toward offering comfort care led to more hospice and early comfort-care orders. Is this due to chance alone, given the multiplicity of secondary outcomes examined? Or is it a tantalizing finding that suggests a remarkably low cost EHR based nudge might, on a population level, lead to critical care clinicians offering comfort care and hospice more frequently? Imagine! -Alex Smith

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