problem where all possible alternatives are known , and the optimum outcome is chosen . It has been used in healthcare settings although Chapman & Sonnenberg ( 2000 ) argue this may not fit well with unpredictable environments or critical situations . Most studies of heuristics and bias in clinical decision making are based on hypothetical situations ( Blumenthal-Barby & Krieger , 2014 ) which lends some doubt to the external validity of these findings . A systematic review by Saposnik et al ( 2016 ) concludes that in reality these theories have little practical application . In contrast , ‘ naturalistic ’ decision making describes making decisions in reality rather than in hypothetical situations ( Harencarova , 2017 ). Paramedics often have to make decisions on scene without access to other opinions as would be easily available in a hospital setting ( O ’ Hara et al , 2015 ). These decisions , which are heavily influenced by individual competence and confidence , may result in paramedics being disproportionately risk averse , as non-conveyance is often seen as risky for both patient and paramedic ( O ’ Hara et al , 2015 ).
Rasmussen ( 1983 ) developed a ‘ Skills , Rules , Knowledge ’ model of decision making which encompasses three discrete levels of performance . This model suggests that in the first instance a person will use learnt sensorimotor skills to tackle a problem , but if this is insufficient , they will then apply rules or protocols . The third level , knowledge based behaviour , is activated when neither appropriate learnt skills nor rules are available . In Albert ’ s case , it could be argued that the physical assessment ( Jarvis , 2015 ) constituted the motor skills , but while this offered a diagnosis it left insufficient information to solve the problem . Had he already been in cardiac arrest , then clinical practice guidelines ( Joint Royal Colleges Ambulance Liaison Committee , 2017 ) would provide a protocol for resuscitation or Recognition of Life Extinct ( ROLE ) dependent on circumstances , although Eccles & Grimshaw ( 2000 ) argue that protocols may cause increased problems as they offer a single solution to a complex problem . However , the decision around Albert ’ s treatment was not covered by these guidelines so knowledge of his condition was drawn upon , supported by the information from his wife to make a judgment in his best interests . Vincent ( 2002 ) proposes that human errors in decision making can be attributed to a combination of skills-based , rules-based or knowledge-based failures .
Klein et al ( 1993 ) formulated a ‘ Recognition- Primed ’ decision making model , which relies on the recognition of a situation followed by the identification of an appropriate response . Although developed with and for firefighters , Harencarova ( 2017 ) posits that it is equally applicable to the unpredictable world of pre-hospital care . This model highlights that experience is used , possibly more than analysis , to inform decisions . Paramedics from student through to advanced level showed not only that they can use , but that they prefer rational decision making ( Jensen et al , 2016 ). Stanovich & West ( 2014 ) counter that while most clinicians would like to believe they use critical thinking to analyse a problem and reach a solution , there is strong evidence to suggest that most decisions are made by rapid pattern recognition . In Albert ’ s situation , diagnosis of his life-threatening aortic dissection was made using pattern recognition . The potential responses were to treat him aggressively and transport rapidly to hospital ; to wait for the inevitable cardiac arrest and begin resuscitation ; or to take a holistic approach , considering not only Albert but his wife , too , and allow him a natural death . Knowing that his AAA had already been deemed inoperable meant that treatment and transport would offer no benefit , and that attempted resuscitation of cardiac arrest would be futile ( Wahlberg & Goldstone , 2017 ).
It was not clear whether any advance care plan or directive had been discussed with Albert and his wife , however discarding the first two responses left only one course of action .
Kahneman ( 2011 ) proposed a dual processing theory of cognitive thinking . In this theory , system one , or fast thinking is intuitive and relies on pattern recognition and individual bias whereas system two , or slow thinking , is more deliberate and requires more effort and attention . Under increased cognitive load or emotional burden , system two thinking may fail and revert back to system one ( Kahneman , 2011 ). Allan ( 2017 ) posits that although system one thinking can correctly make life or death decisions based on limited information , it is inherently prone to error