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Getting the End-of-Life Directive: Should Nudging Be the Strategy?

This leadership challenge presented in this case, in reality, presents two consumer decision-making realities within one case. In Marys first experience as a medical groups leader, she attempted to constrain a group of professionals decision freedom. The result was less than positive by trying to order them in terms of when they had to complete the medical records on patients. In her new position, she has a legitimate concern with the senior patient population. Mary is correct in that it is a two-tier problem, but the second question is the primary challenge. In this case, it may well be that a nudge may be better than a push.

1. What would be an effective nudge to the physician that would result in a response for the group to change?

2. Which consumer decision-maing model would you recommend and why?

Study:

Dr. Mary Arnoldson was recently recruited to be the new vice president of Medical Affairs of a large multi-specialty medical practice in the Northwest. The organization has been a market share leader and has had a strong reputation as it has been in the community for over 85 years. Although it has almost 200 physicians, the group decided it was time to bring in some new leadership with a fresh perspective. The age distribution of the clinical staff was skewing on the more senior side, and the group recognized it was important to provide a new infusion for its future health and to be able to continue to ensure its viability for the health of the community. That said, it was a practice that was fairly set in its ways. Mary was excited to join the practice. Having been a practicing internist for fifteen years, she served as her own original groups president for five years and then became her hospitals chief medical officer for another five years in a major midwestern city having originally trained in the Northwest, she had always wanted to return to the region and looked forward to this opportunity. As Mary reviewed the practice and became familiar with the many facets of the care system, she was impressed with the quality of the care team, the service delivery, and the overall professionalism of the practice. She remembered from her days in training in her residency program how committed people seemed and was not surprised that this perspective continued today. Interestingly, there was one thing that did stick with her as a small but important issue to address. A significant number of the patient population under the practices care were seniors. Of this group, a large number had not completed advanced directives, indicating their end-of-life instructions. Mary felt this was something the physicians should be involved in and get into the patient record as part of the holistic aspect of being involved in their patients care. However, in dealing with this issue and physician behavior, Mary reflected on how to best achieve this goal. With Marys experience as a physician leader, she recognized that issuing orders was not the best way to gain compliance. Mary thought back to her first experience when she was her groups president. It was a rocky start that she recalled quite well and certainly learned the lesson. Physicians, as all professionals, are not a group that likes to be ordered to do something. Highly skilled and educated, an order is a threat to autonomy, she realized. When she told physicians she wanted all notes on patients completed within 24 hours, it came across as a command. Her time as the groups president was almost the shortest on record. However, with some reflection and a couple supportive colleagues, Mary recovered and brought the group together with a collective solution. Now, she thought the objective here in her new group was a good one, but she did not want to repeat her error. She wondered now how she could institute some way to get the physicians to respond and gain patient compliance to this important end-of-life directive. The countrys recent Covid-19 experience underscored the need for these orders for anyone over the age of 70. Mary viewed this problem as a two-tier issue. Should she have an objective number for each doctor where there is a percentage goal for each to complete based on their patient base? Or should some pact be developed whereby the goals are agreed upon across the physician practice? The more central question, however, was how should she move the physicians to compliance with a program of getting end-of-life directives from their older patients