Understanding Decision Making in Critical Care

Abstract

Background: Human decision making involves the deliberate formulation of hypotheses and plans as well as the use of subconscious means of judging probability, likely outcome, and proper action.

Rationale: There is a growing recognition that intuitive strategies such as use of heuristics and pattern recognition described in other industries are applicable to high-acuity environments in medicine. Despite the applicability of theories of cognition to the intensive care unit, a discussion of decision-making strategies is currently absent in the critical care literature.

Content: This article provides an overview of known cognitive strategies, as well as a synthesis of their use in critical care. By understanding the ways by which humans formulate diagnoses and make critical decisions, we may be able to minimize errors in our own judgments as well as build training activities around known strengths and limitations of cognition.

Keywords: Critical care; Diagnosis; Heuristics; Intuition; Medical decision making.

Figure 1

A schematic of dual cognitive processes in clinical decision making is shown. A situation or problem requiring a decision activates both pathways simultaneously; however, a path of least resistance is taken. Familiarity with the situation favors the faster non-analytic pathway on the left (System I), while novelty and complexity call for greater analysis and likely use of System II. The thicker arrow on System I is used to indicate a more direct connection and path of lesser resistance than that for System II. Plus and minus signs are shown alongside factors that have been shown to positively or negatively influence the overall quality and output of each system. The dashed arrow, whereby System II provides oversight of tentative conclusions reached by System I, represents metacognition.