Use of Cognitive Shortcuts in Decision-making for Children With Severe Neurologic Impairment

A couple presents to maternal fetal medicine clinic 3 days after a routine prenatal ultrasound at 19 weeks revealed a brain malformation consistent with severe holoprosencephaly in an otherwise normal appearing fetus. Clinicians share with the parents that many families decide to terminate their pregnancy in this situation on the basis of the likelihood that their child will have lifelong severe neurologic impairment (SNI) and require frequent hospital and medicalized home care. Without much further discussion, the couple immediately responds that they will continue their pregnancy. They express hope that their infant’s health will be better than doctors anticipate.

Presenting at term in labor with brain abnormalities confirmed on ultrasound, the obstetric clinicians ask the parents about their goals of care. The couple again shares that they remain hopeful and that they would like every intervention done to help their child survive. The infant emerges lethargic and without respiratory effort requiring intubation in the delivery room and admission to the NICU. At the time of birth, the parents share that they are feeling a mix of surprise, anger, joy, and sadness. Over the subsequent months, the infant continues to show signs of SNI, grows well after a gastrostomy tube is placed, and remains intubated for intermittent apnea and airway obstruction. After discussions with the neonatology and surgery teams, the parents agree to a tracheostomy in hopes that this will enable them to eventually reach their goal of bringing their infant home.

This case is rife with the types of decisions parents and clinicians face in the care of infants and children with congenital and anatomic brain abnormalities resulting in SNI.^1,2  These decisions can be challenging. They are high stakes, have no single correct choice, and are dependent on parent values and preferences.²  Parents and clinicians may experience heightened stress and strong emotions in these difficult situations, making disagreements likely.^3,4  Despite this, clinicians must work with families to select the best course of action for their particular child among several preference-sensitive options.² 

A complicated and often underappreciated aspect of the process of aligning parental values and preferences with treatment options is the use of cognitive shortcuts. Cognitive shortcuts are the automatic thought patterns that people use to make decision-making more efficient.⁵  They are frequently used in response to stress and complex time-limited decision-making.⁵  At times, the use of cognitive shortcuts can be beneficial and even necessary. In other situations, however, cognitive shortcuts can be misapplied and result in biased decision-making.

Biased decision-making through the misapplication of cognitive shortcuts has particular relevance in decision-making for children with SNI because uncertainty, strong emotions, value judgements, and preference-sensitive options are the norm.⁶  Parents of children with SNI who misapply a cognitive shortcut may choose a course of action in the moment without fully considering why they prefer that option and how it aligns with their values. Similarly, clinicians who misapply cognitive shortcuts may recommend a specific treatment option without deeply considering and understanding the parents’ values and preferences.

In the case presented, for instance, the couple may be employing the representativeness cognitive shortcut to estimate the likelihood of their child's prognosis. This may ultimately lead to a biased estimation, optimism bias, in which the parents underestimate the probability of a bad outcome. Similarly, clinicians may recommend comfort care in these situations because of their tendency to underestimate a family’s resilience to adapt to an unanticipated outcome or overestimate the impact of a negative outcome (ie, impact bias). As another example, parents may choose more action-oriented interventions, such as proceeding with resuscitation, as opposed to less action-oriented options, such as comfort care for their child, resulting in commission bias (Table 1). We think greater recognition of the cognitive shortcuts used by both parents and clinicians can help signal the opportunity to provide better support by (1) slowing down the decision-making process to ensure adequate elicitation of parental values and time for emotional processing, and (2) perspective taking.

When medical decision-making for children with SNI is time-sensitive, it may increase the likelihood that cognitive shortcuts are not only used during the decision-making process but, also, misapplied.⁷  To the extent possible, slowing down the decision-making process may therefore have many potential benefits. Slowing down may allow parents time to further consider medical information and how it relates to their values, allowing them to be more deliberative in their decision-making. These deliberations may yield deeper insight into what different decisions mean for their child and family. This does not necessarily mean that parents will make different decisions but, rather, that there will be space to explore options more fully. Similarly, slowing down may allow more time for clinicians to elicit family values and explore how they may impact medical recommendations. Although uncertainty and preferences will remain, slowing down may provide an opportunity for parents and clinicians to further evaluate different treatment options together.

Time may also give space for parents and clinicians to process their emotions.⁷  Clinicians can acknowledge emotions by empathizing and aligning with parents. In the case presented, a clinician might say, “I am sorry to share this hard news. I can’t imagine how you both might be feeling.” By slowing down, clinicians can also reflect on their own emotions and how they may result in the use of cognitive shortcuts that may, ultimately, be influencing their medical recommendations. The act of slowing down may enable the emotional processing necessary to understand how cognitive shortcuts are impacting decision-making, particularly when emotions result in biased decisions that do not reflect values.

Through an appreciation of cognitive shortcuts and how their misapplication can result in bias, clinicians may also be better able to understand parent perspectives during the decision-making process. Recognition of cognitive shortcuts may indicate the need for engaged curiosity, a key component of empathy toward the experiences and perspectives of other people.⁸  This curiosity can be facilitated by questions like “what worries you most right now?” and “what are you most hoping for?”: answers to which may generate a better understanding of parental decisions, even when those decisions differ from clinician recommendations.

It is important to consider the use of cognitive shortcuts and the biases that can result with their use by parents and clinicians in decision-making for infants and children. Recognizing their use can improve decision-making in stressful, emotionally charged, preference-sensitive situations. We have highlighted how cognitive shortcuts and biases can manifest in the context of an infant with SNI. In clinical practice, clinicians should recognize the use of cognitive shortcuts not only by parents but, also, in their own deliberations. This requires an open attitude, sense of self-awareness, and humility toward the values and preferences of others. In these instances, clinicians can slow down the decision-making process to elicit values and preferences and support the emotional processing that enables perspective taking. This can be accomplished by presenting future decisions well in advance with families, sharing information in a separate conversation then when decisions need to be made, and listening with curiosity to emotions and values. By examining the use of cognitive shortcuts and bias, we may be able to diminish stress during decision-making and provide the empathetic support essential to the care of children, their parents, and their clinicians.

SNI

severe neurologic impairment