Nudging Toward Hospice -- Do Behavioral Interventions Improve ICU Care?

Background: ICU guidelines recommend that clinicians offer comfort-focused care options and discuss prognosis with seriously ill patients, but these conversations are often delayed or not documented. Objective: To determine whether nudges in the electronic health record (EHR) improve outcomes and end-of-life care practices for critically ill ICU patients. Design: Pragmatic, stepped-wedge cluster-randomized trial. Participants/Methods: The study was conducted across 17 medical and surgical ICUs in 10 hospitals in North Carolina (2018 to 2020), including adults with serious preexisting illness (chronic obstructive pulmonary disease, amyotrophic lateral sclerosis, malignancy) on ≥48-hour mechanical ventilation. Among these patients, an EHR-embedded algorithm identified those at high mortality or serious morbidity risk. Clinicians received 1 or both of 2 EHR nudges as follows: (1) prognosis, asking clinicians to document a 6-month functional prognosis; and (2) treatment alternative, a more...