Skip to main content

Star Wars, Behavioral Economics, Geriatrics, and Palliative Care


Obi-Wan: "These are not the droids you're looking for."
Stormtrooper: "These are not the droids we're looking for."
Obi-Wan: "He can go about his business."
Stormtrooper: "You can go about your business."
Obi-Wan: "Move along."
Stormtrooper: "Move along....move along."

What if there was a tool, or set of tools that could influence our behavior in ways that we didn't recognize, or even denied?  Would you call it The Force?

Well it turns out there is such a force, and it's called behavioral economics.  I recently finished reading a  book by Daniel Kahneman called Thinking, Fast and Slow.  Kahneman won the Nobel Prize for his landmark research that led to the field of behavioral economics.  The idea is that you can alter the context in which decisions are made. You can take advantage of the irrational (fast) way in which humans are hardwired to make decisions.

My question is, how can we harness this force for the good of geriatrics and palliative care?

Here is a brief primer on the methods of behavioral economics, the mnemonic MINDSPACE courtesy of some folks from the UK:
  • Messenger: We are heavily influenced by who communicates information
  • Incentives: Our response to incentives is shaped by predictable mental shortcuts such as strongly avoiding losses
  • Norms: We are strongly influenced by what others do
  • Defaults: We "go with the flow" of pre-set options
  • Salience: Our attention is drawn to what is novel and seems relevant to us
  • Priming: Our acts are often influenced by subconscious cues
  • Affect: Our emotional associations can powerfully shape our actions
  • Commitments: We seek to be consistent with our public promises, and reciprocate acts
  • Ego: We act in ways that make us feel better about ourselves
This is not coercion.  There is a perfectly ethical way to use behavioral economics.  I'm returning from a Greenwall conference where some very prominent bioethicists are thinking about how to use these tools for the good.  The context is already there, we just need to do a better job of attending to the message and subconscious cues the context is sending.

Here are some examples to prime the pump of ideas:
  • Default of full code.  Consequently, most hospitalized patients and nursing home residents (I think) are full code
  • The Choosing Wisely Campaign: Re-setting medical norms around ordering tests and treatments.  It's just not OK to be slathering on that ABH gel!  Everyone else has stopped doing it! (or at least I hope AAHPM wisely chooses ABH gel as verboten)
  • Paying hospitals a bonus up front, then taking away money if patients develop urinary tract infections in the hospital.  Hospital administrators value losses (taking away money) more than gains (a bonus at the end). (In this example, the paper says no difference was found after the up-front incentive was started.  More likely hospitals started changing their behavior the moment they heard the payment incentives were going to start, before folks in this study started measuring outcomes).
I look forward to your thoughts on how we can use behavioral economics to improve the quality of geriatrics and palliative care for older adults.

And now I have to run, I feel a tremor in the force...I have not felt that since...

by: Alex Smith @alexsmithMD

Comments

Anonymous said…
Great area of study! Why we do what we do is probably more important that what we do! Two other books I highly recommend on this brain science decisioon making topic are Nudge by Richard Thaler and Cass Sunstein that review the scince of " decision architecture" and why it works.
Another book I'm currently plowing through is Incognito by David Eagleman that talks about how in the world and ourselves goes on at an unconsious level.

Popular posts from this blog

The Dangers of Fleet Enemas

The dangers of oral sodium phosphate preparations are fairly well known in the medical community. In 2006 the FDA issued it’s first warning that patients taking oral sodium phosphate preparations are at risk for potential for acute kidney injury. Two years later, over-the-counter preparations of these drugs were voluntarily withdrawn by the manufacturers.  Those agents still available by prescription were given black box warnings mainly due to acute phosphate nephropathy that can result in renal failure, especially in older adults. Despite all this talk of oral preparations, little was mentioned about a sodium phosphate preparation that is still available over-the-counter – the Fleet enema.

Why Oral Sodium Phosphate Preparations Are Dangerous 

Before we go into the risks of Fleet enemas, lets spend just a couple sentences on why oral sodium phosphate preparations carry significant risks. First, oral sodium phosphate preparations can cause significant fluid shifts within the colon …

Length of Stay in Nursing Homes at the End of Life

One out of every four of us will die while residing in a nursing home. For most of us, that stay in a nursing home will be brief, although this may depend upon social and demographic variables like our gender, net worth, and marital status. These are the conclusions of an important new study published in JAGS by Kelly and colleagues (many of whom are geripal contributors, including Alex Smith and Ken Covinsky).

The study authors used data from the Health and Retirement Study (HRS) to describe the lengths of stay of older adults who resided in nursing homes at the end of life. What they found was that out of the 8,433 study participants who died between 1992 and 2006, 27.3% of resided in a nursing home prior to their death. Most of these patients (70%) actually died in the nursing home without being transferred to another setting like a hospital.

 The length of stay data were striking:

the median length of stay in a nursing home before death was 5 months the average length of stay was l…

Palliative Care in Nursing Homes: Discussion of a Multinational Trial with Lieve Van den Block

Nursing homes are a tough place to do palliative care.  There is extremely high staff turnover, physicians are often not present except for the occasional monthly visit, many residents die with untreated symptoms usually after multiple hospitalizations and burdensome life-prolonging treatments, and specialty palliative care - well that is nowhere to be found in most nursing homes outside of hospice.  So what can we do to improve the palliative care outlook in nursing homes?

On todays podcast we talk with Lieve Van den Block about her recent palliative care intervention that was published in JAMA IM this week.  Lieve led a multicomponent intervention to integrate basic nonspecialist palliative care in in 78 nursing homes located in 7 different European countries.  Just take a moment to grasp the size of this study - 7 counties, 78 nursing homes.  I struggle with just trying to improve palliative care in one site!

We discuss with Lieve the results of the study, her take on why they got…