Semin Neurol 2023; 43(05): 735-743
DOI: 10.1055/s-0043-1775596
Review Article

Cognitive Biases and Shared Decision Making in Acute Brain Injury

Alexis Steinberg
1   Department of Critical Care Medicine, Neurology, and Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
Baruch Fischhoff
2   Department of Engineering and Public Policy, Institute for Politics and Strategy, Carnegie Mellon University, Pittsburgh, Pennsylvania
› Author Affiliations


Many patients hospitalized after severe acute brain injury are comatose and require life-sustaining therapies. Some of these patients make favorable recoveries with continued intensive care, while others do not. In addition to providing medical care, clinicians must guide surrogate decision makers through high-stakes, emotionally charged decisions about whether to continue life-sustaining therapies. These consultations require clinicians first to assess a patient's likelihood of recovery given continued life-sustaining therapies (i.e., prognosticate), then to communicate that prediction to surrogates, and, finally, to elicit and interpret the patient's preferences. At each step, both clinicians and surrogates are vulnerable to flawed decision making. Clinicians can be imprecise, biased, and overconfident when prognosticating after brain injury. Surrogates can misperceive the choice and misunderstand or misrepresent a patient's wishes, which may never have been communicated clearly. These biases can undermine the ability to reach choices congruent with patients' preferences through shared decision making (SDM). Decision science has extensively studied these biases. In this article, we apply that research to improving SDM for patients who are comatose after acute brain injury. After introducing SDM and the medical context, we describe principal decision science results as they relate to neurologic prognostication and end-of-life decisions, by both clinicians and surrogates. Based on research regarding general processes that can produce imprecise, biased, and overconfident prognoses, we propose interventions that could improve SDM, supporting clinicians and surrogates in making these challenging decisions.

Publication History

Article published online:
04 October 2023

© 2023. Thieme. All rights reserved.

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