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INTRODUCTION

We’ve been trained to believe that clinical decision making is rational and analytic; that emotions get in the way of good decision making. While considerable evidence suggests that emotions do influence decision making and that very strong negative emotional states impair information processing and reasoning, increasing evidence suggests that intuitive deliberation, which relies on affective cues, may produce better outcomes than analytical deliberation alone.

In this chapter, I will focus in particular on decision making in the context of serious illness—in part because it is most often associated with emotion—and because it is my area of clinical research and practice. However, the lessons herein apply to any high-stakes encounter, including those in the emergency room or when a primary care or specialist provider delivers unexpected bad news. Importantly, this chapter will not address other important topics involving emotion and decision making, including race-, class-, and behavior-based biases that influence clinical decision making. In this chapter, I draw on literature from psychology, neuroscience, and economics, as well as clinical medicine. I explore the influences of both patient (or surrogate) and clinician emotion on the decision making of all the parties involved. I also demonstrate how patient and clinician emotions may interact and how integrated palliative care can mitigate some of the negative impacts and thereby facilitate better decision making.

SERIOUS ILLNESS COMMUNICATION AND DECISION MAKING

Serious illness is defined as “[a] health condition that carries a high risk of mortality and either negatively impacts a person’s daily function or quality of life or excessively strains the caregiver.”1,2 Because of the stakes and strains, communication and decision making regarding serious illness elicit strong emotions in patients, caregivers, and clinicians.

Case 1

“I have lots of patients who do really well!”

You are an oncologist seeing a patient with newly diagnosed metastatic (Stage IV) pancreatic cancer. This is your first meeting and the purpose is to establish oncologic care and discuss treatment options. You lay out the details of the currently recommended chemotherapy regimen, including details of dosing regimens, likelihood of side effects, and statistics regarding disease progression and control, citing clinical trial evidence for the newest elements of the regimen. The patient quietly asks you how much time they have, and looks like they are about to cry. You feel your hands getting sweaty and your heart beating faster. You feel the overwhelming urge to reassure them, to make them less sad and scared. You know the National Comprehensive Cancer Network (NCCN) survival statistics by heart because you just took the boards, but instead this pops out of your mouth: “I don’t have a crystal ball. Everyone is different. I have lots of patients who do really well!”

This case has multiple layers. You felt anxious and panicked in response to the question about prognosis, so different from your calm and composed self a few ...

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