P0476 - Pediatric Intensivists' Perspectives on Nudging

Background:
Nudging is a behavioral economics term describing types of choice architecture that affect behavior predictably without eliminating alternative options. Nudging has been studied in medicine, mostly in adults, but there is no literature on its use in the Pediatric Intensive Care Unit (PICU). Shared decisions with families are made frequently in the PICU, where nudging likely occurs. However, some may view nudging as impeding parental authority and limiting choice. A survey to gauge pediatric intensivists’ perspectives on nudging will help us understand how ethically permissible providers believe these techniques to be.

Objectives:
To gauge pediatric intensivist’s perspectives on nudging, and to evaluate perceptions of ethical permissibility between different forms of nudging.

Methods:
This is a multi-center survey of pediatric intensive care physicians. Investigators sent a REDCap survey to pediatric intensivists at various institutions, who disseminated the survey to their department faculty. Surveys queried demographic data about the provider and the institution in which they practice. Practitioners were presented with 4 clinical scenarios representing framing, saliency and default techniques of nudging. Providers were questioned on their perception of ethical permissibility and frequency of use of each technique, with space to write comments about the nudging techniques.

Results:
402 surveys were distributed, with 132 (33%) completed. Results show wide variability in perceived ethical permissibility in nudging techniques. (Table1) For negative framing, an equal number of physicians found the technique to be “not at all” ethically permissible as “extremely” ethically permissible. The widest variability is with the application of saliency. Negative saliency showed a statistically significant positive correlation with how often the provider uses the technique, and how much that provider believes saliency affects the family’s choice. For a case with severe traumatic brain injury, respondents found negative saliency to be more ethically permissible than positive saliency. However, this was reversed with a case regarding a tracheostomy, with positive saliency viewed as more ethically permissible. Qualitatively, variable responses were given for each technique, such as for framing (“Families should be coached into making a decision for their child, which framing can do” vs “Framing is imposing the medical team's opinion on the family”) and for saliency (“It is inappropriate to paint the family into a corner, making them feel bad if not moving toward a [specific] decision” Vs. “I think it is important to include saliency…so that the family can understand the real-life impact of the medical condition”). Providers reported a wide range of use of nudging techniques (Table3).

Conclusion:
Our survey results suggest wide variability in both utilization practices and opinions on the use of nudging in discussions regarding critically ill children. Further understanding of choice architecture is essential to understand how physicians can optimally engage in shared-decision making with families.