Cognitive bias and planning error: nullification of evidence-based medicine in the nursing home

Medical error is common, and has a large impact on our national healthcare budget. The elderly and chronically ill are among the largest consumers of the Medicare budget fueling interest in avoiding unnecessary hospitalizations among nursing home residents. In addition to preventive measures involving care coordination and better implementation of advanced directives, this article argues that many nursing home residents have a greatly inflated risk of hospitalization and would benefit from more intensive medical management.

Reflective practice is used to analyze why nullification error (inappropriately omitting evidence-based treatments) regularly occurred among nursing home residents over an 8-year period. The study frames the root causes of clinical inertia and nullification error using terms from cognitive psychology and contemporary philosophy.

Unrecognized biases and cognitive pitfalls are the basis for why competent physicians reject evidence-based medicine (EBM) in the nursing home. Six common recurring nullification errors are discussed with the proposed root causes. A glossary of unfamiliar terms is included.

The uncertainty over the appropriateness of EBM for the nursing home patient has led to a widespread bias toward undertreatment that has reached alarming proportions. It is true that most elderly patients do not wish to extend their life expectancy, but most do wish to avoid medical complications and unnecessary hospitalizations. Rejecting treatments that extend life expectancy often results in rejection of the very treatments that would improve the probability of achieving their wish to retain fair health. Practitioners do not reject meaningful treatments because of lack of knowledge or lack of concern. They do so because of an incomplete education regarding the biases and cognitive pitfalls that are encountered when planning care for the elderly.