Nudging During Pediatric Intensive Care Conferences With Family Members: Retrospective Analysis of Transcripts From a Single-Center, 2015-2019.

OBJECTIVES: Nudging, a behavioral economics concept, subtly influences decision-making without coercion or limiting choice. Despite its frequent use, the specific application of nudging techniques by clinicians in shared decision-making (SDM) is understudied. Our aim was to analyze clinicians' use of nudging in a curated dataset of family care conferences in the PICU. DESIGN: Between 2019 and 2020, we retrospectively studied and coded 70 previously recorded care conference transcripts that involved physicians and families from 2015 to 2019. We focused on decision-making discussions examining instances of nudging, namely salience, framing, options, default, endowment, commission, omission, recommend, expert opinion, certainty, and social norms. Nudging instances were categorized by decision type, including tracheostomy, goals of care, or procedures. SETTING: Single-center quaternary pediatric facility with general and cardiac ICUs. PATIENTS: None. INTERVENTIONS: None. MEASUREMENTS: We assessed the pattern and frequency of nudges in each transcript. MAIN RESULTS: Sixty-three of the 70 transcripts contained SDM episodes. These episodes represented a total of 11 decision categories based on the subject matter of nudging instances, with 308 decision episodes across all transcripts (median [interquartile range] 5 [4-6] per conference). Tracheostomy was the most frequently discussed decision. A total of 1096 nudging instances were identified across the conferences, with 8 (6-10) nudge types per conference. The most frequent nudging strategy used was gain frame (203/1096 [18.5%]), followed by loss frame (150/1096 [13.7%]). CONCLUSIONS: Nudging is routinely employed by clinicians to guide decision-making, primarily through gain or loss framing. This retrospective analysis aids in understanding nudging in care conferences: it offers insight into potential risks and benefits of these techniques; it highlights ways in which their application has been used by caregivers; and it may be a resource for future trainee curriculum development.

Whole-lake acoustic telemetry to evaluate survival of stocked juvenile fish.

Estimates of juvenile survival are critical for informing population dynamics and the ecology of fish, yet these demographic parameters are difficult to measure. Here, we demonstrate that advances in animal tracking technology provide opportunities to evaluate survival of juvenile tagged fish. We implemented a whole-lake telemetry array in conjunction with small acoustic tags (including tags < 1.0 g) to track the fate of stocked juvenile cisco (Coregonus artedi) as part of a native species restoration effort in the Finger Lakes region of New York, USA. We used time-to-event modeling to characterize the survival function of stocked fish, where we infer mortality as the cessation of tag detections. Survival estimates revealed distinct stages of juvenile cisco mortality including high immediate post-release mortality, followed by a period of elevated mortality during an acclimation period. By characterizing mortality over time, the whole-lake biotelemetry effort provided information useful for adapting stocking practices that may improve survival of stocked fish, and ultimately the success of the species reintroduction effort. The combination of acoustic technology and time-to-event modeling to inform fish survival may have wide applicability across waterbodies where receiver arrays can be deployed at scale and where basic assumptions about population closure can be satisfied.