When Thinking is Hard: Managing Decision Fatigue

• Avoid unnecessary decisions. If you don’t have to make a commitment right this minute, you won’t. (This is better known as procrastination.)
• Choose the easiest of the available options. If “do nothing” is an option, you’ll do that. If one path is longer, harder or more complex, you’re unlikely to pick it. If sorting through the choices will take a great deal of thinking or analyzing, you may just pick the first thing that comes to mind or choose arbitrarily.
• Make decisions driven by immediate motivations, such as fatigue or hunger, ignoring long-term or difficult to observe consequences.
• Choose using inaccurate and inappropriately simplified algorithms, stereotypes or “rules of thumb,” rather than thinking through the full breadth of a problem.
• In general, lose your inhibitions and behave impulsively; you may, in fact, resemble someone who’s been drinking.

Implications for EMS

Although decision fatigue seems to affect nearly everyone, those of us who work on ambulances are especially vulnerable.

For one thing, we have a great deal of responsibility, backed by relatively little training and experience. In another field, the equivalent of a green EMT would be an entry-level position, working directly under close supervision by managers and superiors. But in EMS, we do our work on the road—in homes, on the street, in facilities or hidden in the back of the truck. Most of the time there’s nobody to witness the decisions we make except a partner. So there’s no built-in system for enforcing good decisions, and if we make bad ones it may not yield any obvious feedback unless it happens to come back to our supervisors as a complaint or CQI.

And it’s not like we’re short on decisions to make. Not just the big stuff—even when we’re dragged-through-the-mud tired at the end of shift, we can usually muster up the energy to perform a bang-up job on the multiple shooting or cardiac arrest—but what about all the little things that happen before that? After the call an hour ago, did you take the time to sanitize your gear? Perhaps you know that you ought to, that cross-contamination causes infectious complications which can kill your sick patients, but it’s hard to truly imagine that outcome, and it doesn’t seem very likely. At noon, you’ll do it. But how about at 5 a.m. after a 24-hour shift?

Our job is full of decisions like this—things we can do or not do, where there is a clear “right” and “wrong,” but where the difference may not always seem profound, or where the harm seems too distant to care about. As one study worded it, the ramifications are “potentially real (though relatively minor).” If we have a weak moment, fail to sanitize that stretcher, carry over a MRSA colonization to another patient, and they end up with a two-week ICU stay, we will probably never hear about it—and even if we do, we still can’t be sure it was a consequence of our decision. (Maybe he picked it up elsewhere.) The same goes for intangible damages like contributing to inefficient systems, detracting from the professional respect in our field, and causing pain and suffering which could have been prevented.

Long story short, you can do everything right in this job, but every minute of every hour, you’ll have to freely choose to do so.

To make things worse, we habitually work long hours and draining schedules, which as we’ve seen is a recipe for testing your self-control. You may be an angel for four hours, or six hours, but what about in hour 16, or 24, or at midnight on your 80th hour of the week? Everybody has a limit, and once you reach it you should probably go home. But we don’t. On top of that, we tend to maintain poor dietary habits, and by playing yo-yo with our blood glucose we further tax our mental resources.

Finally, although the moment-to-moment business of EMS gives us ample freedoms, many times we may feel confined by the larger framework we work in—our employers, our protocols, or even the shape and direction of our industry as a whole. And the evidence suggests that when we perceive our actions as autonomous or enjoyable, our tolerance for decision “drain” is greater. How empowered do you feel in your job? Do you always enjoy every call?

Solutions

How can we combat this tide of will-draining, energy-sapping ego depletion?

The single best way is to reduce our decision load to begin with. One of the most interesting findings in the studies on decision fatigue is which types of people seem to manage it best. By and large, those individuals who could conserve willpower the longest and maintain the highest quality in their decisions weren’t doing it by being tougher than the rest of us. They weren’t adhering to higher principles or demonstrating stronger character. Instead, they simply set up their circumstances to minimize the amount of self-control they’d need to exert. They planned ahead. They scheduled, made lists, finished to-do’s early, and handled problems before they escalated. They built their lives so that they wouldn’t need to make as many decisions.