Irrational agency – it’s irrational to expect rational agency

Too little attention is paid to the social nature of making decisions. In the Western tradition we assume that the individual is paramount. That you alone are best placed to make decisions in your own best interests. That you are a rational agent. It is an attractive idea. That as individuals we can effectively gather data, evaluate the pros and cons, and decide the best course of action to advance our own goals. Yet this is bunk. In the following series of blogs I will argue that there is a need to radically rethink how healthcare decision making is organised. As evidence I will draw on a sample of one; a story of a 31-year-old gentleman who experienced first hand what can happen when health professionals have an atomised perspective on decision making…

At 16:25 a 31-year-old male patient was brought by ambulance to the Emergency Department  (ED) of a tertiary facility following a fall in the community. The patient has a complex medical history including renal failure, diabetes, hypertension, depression, hepatitis, and resides in a care facility.

On arrival to ED the observations were; blood pressure 170/95 mmHg, heart rate 100 beats per minute, respiratory rate 22 breaths per minute, temperature 36.7 degrees Celsius, SpO2 93% on room air, and the blood glucose level was 43 mmol/L. The examination by a Junior Medical Officer (JMO) identified that there were no injuries from the fall. The patient was admitted for hyperglycaemia, commenced on an insulin infusion and a plan was made for the patient to be dialysed. The patient remained in the ED overnight awaiting an inpatient bed. 

Many hands, many decisions yet little communication

Count the number of professionals who have been involved in this patient’s care. The patient was likely to have been reviewed by a nurse or seen by a nurses’ aide in the care facility. The paramedics have provided care and handed over to the triage nurse. The patient was then seen in ED by a Registered Nurse (RN) and a JMO (JMO number 1). At least five professionals so far…

At 22:30 the patient had an unwitnessed fall out of bed in an attempt to go out for a cigarette. The patient was assisted back to bed by medical and nursing staff. At 22:50 the patient fell out of bed again; at this point he was reviewed by a JMO (JMO number 2). There were no injuries identified on review. The next morning the patient was admitted to a general medical ward.

With each incident the number of professionals who have interacted with the patient has increased. The patient has now been reviewed at least twice by two different JMOs and been cared for by more than four different nurses. But enough about the professionals, what about the patient?

The importance of trust

The patient has lost most, if not all of his agency. He has not chosen to place himself in the care of medical officers and nurses. He has not chosen to trust these professionals. When patients have the capacity to choose they will only relinquish their own agency for good reason. Usually to those perceived as having superior knowledge; hoping that these professionals have their best interests at heart. The importance of this trust is reflected in the magnitude of the decisions that patients allow health professionals to make. Sometimes the outcome of these decisions can result in pain, disability, and even death.

Yet without trust in health professionals, the professions would cease to exist. For example, would you pay to see a doctor if you did not trust that they understood the situation better than you, or if you suspect that she will take advantage of your vulnerability? Of course not! You are rational and you have agency. You choose to engage in a process of decision making involving a patient/yourself and a trusted physician. It is an interaction characterised by information asymmetry; for this reason trust is paramount. As professionals we have a responsibility to honour this relationship of trust.

For the patient in our story the opportunity to choose who to trust is moot. Agency has been removed (not against his wishes but without anyone asking). So vanishingly little agency is left that he no longer has the opportunity to enjoy a cigarette. Let’s return to our story…

A lack of documentation

At 12:50 hours, on the general medical ward, our patient was reviewed by an experienced renal JMO (JMO number 3) and it was identified that the patient had shooting leg pain and back pain. A spinal assessment revealed that the spine was tender everywhere and an X-ray was ordered of the thoracolumbar spine. Soon after the patient attended the dialysis unit. 

Before dialysis the patient was weighed. While standing on the scales the patient complained of bilateral leg weakness and back pain. At this point he was reviewed by a less experienced JMO (JMO number 4). The JMO (4) charted analgesia. Following dialysis the patient was transferred back to the medical ward. He arrived at 21:30 and at this time it was documented by a RN that the patient was complaining of shooting pain in his lower back and altered sensation in his upper thigh. The patient had bilateral lower limb weakness. The RN communicated these findings to the medical officer covering the ward for the evening. The registered nurse noted that this appeared to be a new clinical finding; there was no documentation of any of the previous assessments.

Irrational agency and the slippery nature of agency in general

At this point in our story the patient has been in hospital for about seventeen hours. In these seventeen hours he has had two unwitnessed falls, complained of new pain and altered sensation, had dialysis, and been prescribed analgesics. He has been reviewed by at least four medical officers, and cared for by at least six nurses. That’s a new medical officer every four hours, and a new nurse every three hours. And he still hasn’t had a cigarette!

In this story I have begun to elucidate the slippery nature of agency. I’ve tip-toed towards the argument that rational agency is a thoroughly irrational supposition. We have seen how our patient has lost all sense of control and self-determination; finding himself lost in a sea of concerned faces. Next week we will pick up our story and we will begin to uncover the social and transient nature of decision-making.

This article contains information on a critical incident investigation. Names, dates, and some of the details have been removed or changed to protect the identity of those involved.