as it relies on mental shortcuts . Kahneman ’ s theory may be considered flawed , however , as it is based on an analysis of responses to reasonably complex numerical problems ( Tversky & Kahneman , 1981 ), and does not appear to take into account that numeracy itself requires learning using system two thinking before it becomes intuitive and could be considered system one . In Albert ’ s situation , the initial impression of sepsis was likely system one thinking , recognising a pattern of hypotension , tachycardia and hypothermia . However , this impression was wrong as it was made without sufficient information . Once further information became available regarding Albert ’ s AAA , system two thinking allowed a more analytical approach , deciding to perform a focused assessment to reach a better diagnosis , then using clinical judgement to support a more holistic , patientcentred outcome .
Cognitive bias and personality traits create mental shortcuts , heuristics , which influence the way people think and act , and have been shown to be associated with errors in diagnosis and management ( Saposnik et al , 2016 ) so must be considered in the context of clinical decision making . The anchoring effect describes a situation where the original impression overrides the decision-making process and adjustments are not made when presented with new information ( Tversky & Kahneman 1981 ). Wendt & Tyson ( 2018 ) state that anchoring bias was identified in many studies of error in clinical judgement , however Spaanjaars et al ( 2015 ) found that greater knowledge and experience in the individual clinician reduced anchoring bias .
Confirmation bias is a state of mind where we are more likely to accept , even actively seek out ideas that fit our preconceptions , and ignore evidence to the contrary ( Howard , 2019 ). In Albert ’ s case , an assumption of sepsis was made and subsequent history taking attempted to confirm this before realising an error had been made . Similarly , availability heuristic sets out how the probability of reaching a diagnosis is based on how easily that diagnosis is reached ( Braga et al , 2015 ). Richie & Josephson ( 2017 ) describe how doctors who have cared for patients with sepsis will predict future patients to be at higher risk of this condition .
King ( 2019 ) suggests that the ‘ curse of knowledge ’ affects most professionals at some point during their career , when they realise that their understanding is not shared by all . It seemed obvious to the clinical staff present with Albert that morning that he could not be resuscitated , as all understood the pathophysiology behind his AAA . His wife , however , did not share that knowledge , and so for her , the information had to be communicated in a way that she could understand . The framing effect alludes to the theory that the way outcomes are presented may often result in different choices being made ( Fu et al , 2017 ). When the situation was explained to Albert ’ s wife , she was reminded that his aneurysm was inoperable and a natural , dignified death was deliberately framed in a positive way , leading her to accept the recommendation not to attempt resuscitation .
Outcome bias ( Sezer et al , 2016 ) refers to the tendency for others to judge a decision based solely on its outcome , rather than on the preceding decision-making process . I was aware that when documenting this case , it would appear that a patient had simply been allowed to die without treatment , which would raise questions about not only my practice but that of my crewmate and student , too . This had to be taken into consideration but we were confident that with a detailed patient record we could justify our actions . Ethical practice is a fundamental part of paramedic registration ( HCPC , 2016 ) and includes specific guidance that registrants must treat patients as individuals , respect their dignity and where possible , involve patients and carers in decisions about their care . Healthcare ethics traditionally teaches two theories . Consequentialism is a framework for decision making based solely on the best outcome for the patient ( Dale , 2013 ) whereas the deontological or ‘ duty based ’ approach puts the patient at the heart of the decision making process ( Mandal et al , 2016 ) and encompasses the four pillars of medical ethics : autonomy , beneficence , non-maleficence and justice ( Levitt , 2014 ).
A paramedic is required to make justified decisions to initiate or cease treatment ( HCPC , 2014 ). In Albert ’ s situation , using a consequentialist framework ( Bond & Firenze , 2019 ) I decided that the best outcome was a