Decision Fatigue in the ICU: Physician’s Perspectives and a Typology of Fatigue-Prone Decisions – A Qualitative Interview Study

Decision Fatigue in the ICU: Physician’s Perspectives and a Typology of Fatigue-Prone Decisions – A Qualitative Interview Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Decision Fatigue in the ICU: Physician’s Perspectives and a Typology of Fatigue-Prone Decisions – A Qualitative Interview Study Lorenz Schiessl, Anne Herrmann-Johns, Richard-Felix Kraus, Viktoria Kimmerling, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8797546/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background: The concept of Decision fatigue (DF) originates from research in social psychology and refers to a state of cognitive and self-regulatory exhaustion consequential to repeated decision making. It is assumed that making decisions consumes a limited resource of mental energy which can impair the quality of subsequent decisions. As this resource is depleted, the ability to exercise self-control declines, which can lead to less considered, more impulsive decisions or even no decision at all. Although the concept of DF has been acknowledged over many areas, previous studies in the medical context have shown inconclusive results. This study explored intensive care physicians’ views and experiences on DF and its potential impact on medical decision making in the intensive care unit (ICU). Methods: 19 semi-structured interviews were conducted in person with ICU physicians from October 2024 to March 2025. All interviews were audio-recorded, transcribed verbatim, and analysed using the framework method until data saturation was achieved. Results: 19 physicians from three different ICUs participated, including 13 residents and board-certified specialists in executing roles and 6 consultants with supervisory and treatment-planning responsibilities. Three major themes were identified and developed: (1) DF and mental exhaustion occur in the ICU; (2) DF influences both the decision-making process and the outcome of decisions; and (3) physicians indicate various characteristics of decisions in which the effects of DF are more likely to occur. Conclusions: This study provides new insights into ICU physicians’ experiences of DF. Understanding which decisions are most vulnerable to DF may help guide future research and interventions to support clinical decision-making. Health sciences/Health care Health sciences/Medical research Biological sciences/Psychology Social science/Psychology decision fatigue patient safety staff wellbeing clinical decision making intensive care unit semi-structured interview qualitative research Figures Figure 1 1 Background Making decisions is an essential part of medical practice, whether it involves prescribing medication, evaluating diagnostic information, or performing administrative tasks ( 1 ). A study by Ofstad et al. showed that physicians make an average of 13 clinical decisions per patient contact ( 2 ). According to Baumeister’s resource model of self-regulation, each decision draws on a limited cognitive resource ( 3 ). When numerous decisions must be made within a short period, these resources become depleted, leading to a gradual decline in the ability to make high-quality decisions ( 4 ). As work periods lengthen, individuals tend to make decisions less carefully and rely more heavily on cognitive shortcuts ( 5 ), for example by choosing less effortful or seemingly “safe” options such as postponing decisions or adhering more rigidly to guidelines. This phenomenon is called decision fatigue (DF). Research outside medicine illustrates similar patterns. In a well-known study, Danziger et al. found that judges became increasingly restrictive in their probation decisions as the working day progressed ( 6 ). In another study credit officers showed a decline in loan approvals during midday and late afternoon hours ( 7 ). These findings suggest that DF may influence decision-making across various professional domains. Comparable trends have been observed in clinical work. Studies have demonstrated an increase in the prescription of opioids ( 8 ) and antibiotics for acute respiratory infections ( 9 ) over the course of the day, and surgeons were less likely to perform surgical procedures toward the end of a shift ( 10 ). These examples point to potential fatigue-related shifts in clinical decision-making. However, not all studies have identified such effects. A recent review found that, among 82 included studies, only 45% of those quantitatively assessing DF reported significant associations with diagnoses, test ordering, prescribing, or therapeutic decisions ( 11 ). With only one qualitative study identified, the review highlighted a lack of qualitative evidence, limiting insight into how DF is perceived and managed in everyday clinical practice. The authors concluded that qualitative approaches are needed to provide a more nuanced understanding of DF and to inform the development of targeted interventions ( 11 ). Decision-making in clinical settings is complex and multifactorial. Intensive care units represent an environment that may be particularly susceptible to DF. Due to the patients’ critical condition, even minor decisions have the potential to bear severe consequences, and directly life-threatening situations can arise any time. To deepen understanding of how ICU physicians perceive DF and its contextual influences, we conducted interviews with 19 intensivists to explore their experiences and to identify opportunities for prevention and better management of DF. 2 Methods 2.1 Study Design A qualitative study design using semi-structured interviews was chosen to gain in-depth insights into physicians’ experiences with DF. The interview guide based on an extensive literature review and was developed by an interdisciplinary research team involving physicians and health service researchers. It was pilot tested with two intensive care physicians who were not included in the final sample, and minor adjustments were made prior to data collection. The guide was iteratively refined throughout the interview process to incorporate emerging insights from the data. 2.2 Participants and Recruitment The Ethics Committee of the University of Regensburg issued a declaration of non-objection, confirming that formal ethical approval was not required in accordance with § 15 of the Professional Code of Conduct for Physicians in Bavaria. All methods were performed in accordance with relevant guidelines and regulations and in accordance with the Declaration of Helsinki. Recruitment was carried out through purposive sampling (12) among intensivists of our Department of Anaesthesiology, which runs three surgical ICUs. In order to capture a broad spectrum of different levels of clinical practice and corresponding decision-making experiences and perspectives, junior doctors within their first year of intensive care training, board certified anaesthetists during their specialization in intensive care and finally senior specialists with several years of specialization were invited via email. No incentives were provided. Participants received written and oral study information by the research team. All participants were adults and were provided written informed consent for the participation and the publication of pseudonymised information prior to participation. Nineteen physicians participated in the study, and their demographic characteristics are presented in Table 1. 2.3 Data Collection The interviews were conducted in person by LS between October 2024 and March 2025. They took place during regular working hours in a meeting room at the respective ward to facilitate participation. All interviews were audio recorded using Audacity (13) and pseudonymised before being transcribed verbatim using the transcription function of Microsoft Word 365 (14). 2.4 Data Analysis An inductive approach based on the principles of the framework analysis was used to evaluate the interview data (15). Transcripts were read multiple times to familiarise with the data. Subsequently, meaning units were identified, openly coded, and systematically categorised. Data analysis was supported by MAXQDA software (16), enabling structured organization and management of the data. The first three transcripts were independently coded by two researchers (LS and AL) to ensure the reliability and consistency of the coding process. Any differences in coding were discussed and resolved by consensus. As the analysis progressed, codes were continuously compared, refined, and grouped into higher-level categories. AH provided ongoing supervision and methodological reflection throughout the entire process. Data analysis continued until theoretical saturation was reached, defined as the point at which no new relevant concepts emerged after coding three consecutive interviews (12). → insert Table 1 here Table 1. Demographic data for participants Participant Clinical role Experience working on ICU (years) Gender P1 consultant 1-5 male P2 consultant > 5 male P3 consultant > 5 male P4 consultant > 5 male P5 consultant > 5 male P6 consultant > 5 male P7 resident 1-5 male P8 resident 1-5 male P9 resident ≤ 0.5 male P10 resident 1-5 male P11 resident ≤ 0.5 female P12 resident 1-5 male P13 resident 1-5 female P14 resident 1-5 female P15 resident 0.5-1 male P16 resident 0.5-1 female P17 resident 1-5 female P18 resident ≤ 0.5 female P19 resident 0.5-1 female 3 Results The interviewees comprised 13 residents and board-certified specialists in executing roles, and 6 consultants with supervisory and treatment-planning responsibilities from three different ICUs of a university hospital. The length of the interviews varied from 22–57 minutes and the IQR was 30.5 minutes. Analysis of the data revealed three major themes, which are described in detail below. Mental Exhaustion and Decision Fatigue play an important role in the ICU Most participants reported experiencing mental or physical exhaustion during their shifts, closely linked to the sheer number of decisions (P12) made. Several described a gradual depletion of cognitive energy (P15) over the course of a shift, particularly on days with dense sequences of clinical choices. The accumulation of numerous small and seemingly inconsequential decisions, such as whether a patient may take a sip of water, was perceived as unexpectedly draining and often more exhausting than a small number of major decisions, such as whether a patient should be intubated. Participants noted that DF manifested as a narrowing of mental bandwidth, with routine tasks requiring greater effort and previously straightforward decisions becoming disproportionately effortful. This was attributed to the progressive depletion of attentional and working-memory resources, which reduces the capacity to process information efficiently and increased reliance on low-effort cognitive strategies. The threshold at which DF became noticeable varied substantially between individuals. Rather than a clearly defined moment, participants described a gradual, often subtle onset that became apparent only once they felt mentally slowed or disproportionately strained by routine tasks. They felt that situational factors such as stable staffing levels, predictable workflows, or uninterrupted breaks could delay the emergence of DF, whereas poor physical condition, accumulated stress, or limited clinical experience tended to accelerate it. Although most participants highlighted a link between decision load and fatigue, a few indicated that routine decisions should not impact fatigue or decision quality (P7), reflecting an ideal of cognitive efficiency. However, even they acknowledged that personal circumstances or external pressures occasionally reduced their capacity to handle decision-dense shifts. I think I have a certain number of decisions I can make per day and when I reach a certain moment, I just can’t go on anymore. (P18) The more of these small decisions there are, the more tiring it is, the less motivated you are, the more you want to conserve yourself and avoid this irrelevant petty crap. (P8) Decision-Making as a Core Component of Professional Identity Participants described medical decision-making and the responsibility associated with it as central to their professional identity. Making decisions was not only perceived as an operational necessity but as a meaningful and defining aspect of their role as physicians. It is my task to make decisions, to bring patients forward. A day without decisions feels like a day lost. (P5) I also have the expectation of myself, that I become more independent and am able to act on my own. That’s why I try to make as many decisions myself as possible. (P9) Decision Fatigue influences both the Decision-Making Process and the Outcomes of Decisions Participants reported that DF affected several cognitive and behavioural aspects of decision-making. Concentration commonly declined under high decision load, described as slowing down, not considering certain aspects (P9), with earlier decisions being revised more frequently (P14). Many described increased reliance on heuristics: We’ve been doing it this way recently, so it’s probably fine. (P11 ), framed as low-effort strategies to conserve limited cognitive resources. DF was also associated with greater error-proneness. Participants described re-reading documentation without processing it (P11) and making procedural inaccuracies - especially in medication prescription - despite best intentions, attributed to diminished cognitive capacity rather than negligence (P15). Some became more impulsive, less deliberate, more driven by gut feeling (P8), while others reported the opposite reaction: avoidance, delay, or passing decisions to the next shift. Increased irritability, reduced empathy, and a decline in communication quality were also noted. In particular, participants described that explanations to colleagues, patients and relatives became shorter, less nuanced, and less patient, which occasionally resulted in misunderstanding or dissatisfaction. Physical symptoms such as headaches, tension and general exhaustion further accompanied these experiences. Sometimes in the evening, you sit in front of your computer, and you read the same sentence over and over again without even getting what it says. (P11) Errors happen, you are not as attentive when prescribing meds, well you are putting in effort but you’re just not that capable anymore and make hasty mistakes you wouldn’t if you were rested. (P15) I definitely tend to pass the decision on to someone else. That's just the way it is, to be honest, everyone has to admit that, because I think we all do that to some extent. (P13) Yes, you’re definitely more impulsive, less thoughtful and you make more gut decisions, yes. (P8) Physicians indicate various Characteristics of Decisions in which the Effects of Decision Fatigue are more likely to occur. Results indicate that not all decisions were equally affected by DF. Participants identified specific decisional characteristics that either protected against or amplified the effects of DF. Decision Characteristics associated with lower Susceptibility to Decision Fatigue Emergency situations were consistently described as relatively resistant to DF. Even when fatigued, physicians reported being able to draw on professionalism and remaining concentration (P7) to act effectively. The presence of well-rehearsed algorithms provided some degree of cognitive scaffolding: Emergencies follow fixed routines… I can do that even when I’m exhausted because it’s automatic (P11; P14). Physicians emphasised that in emergencies, action is obligatory despite uncertainty: You might make a wrong decision but doing nothing isn’t an option (P11). They noted that while DF could emerge afterwards, it generally appeared to have limited impact during acute decision-making. Participants described ethically weighty or high-consequence decisions - such as withdrawing life-sustaining treatment, escalating treatment, or determining key diagnostic steps - as less affected by DF. These decisions were typically made collaboratively within a multidisciplinary team (P3, P6), reducing potential impacts of an individual’s DF. Furthermore, such decisions often evolved over days rather than minutes, allowing clinicians to verify information, revisit judgements with a rested mind, and distribute cognitive responsibility across the team. Decision Characteristics associated with higher Susceptibility to Decision Fatigue In contrast, respondents highlighted that certain characteristics make decisions more susceptible to the effects of DF described above. These characteristics are outlined in the following sections. Physical Effort Physicians reported that decisions leading to physical action were more difficult to initiate when fatigued. For example, going to the bedside for a clinical reassessment was sometimes deferred if information could be obtained indirectly, e.g. from the digital patient chart. Physically demanding procedures - such as placing central venous catheters - were more likely to be postponed. One participant explained that when exhausted, they weigh differently how urgent practical tasks are (P17), describing a higher threshold for initiating labour-intensive interventions. And if I ought to do something hands on, despite being completely beat, tired, exhausted, I can’t concentrate anymore, then I weigh up the urgency differently. (P17) Potential Risks and need for further Actions by Physicians Several physicians reported adopting more cautious, conservative decision tendencies when fatigued. One described being less willing to take risks and favouring options with low potential for deterioration or subsequent workload (P10). Another participant stated: If I’m already tired, I’m more likely to choose the approach that won’t trigger a cascade of further decisions (P13). Maintaining the status quo was frequently preferred over proactive intervention when fatigue was pronounced. And when you’re already over your limit, you tend to go for the safer option - or the one that involves fewer decisions - simply because you no longer have the capacity for anything else. (P13) Extensive Cognitive and Time Demands Decisions requiring substantial deliberation or prolonged execution were often deferred due to DF. Participants stated that, deciding whether to do certain tasks was not avoided due to responsibility, but simply because they represented a lot of work (P11). This was particularly evident in dealing with awake, demanding or agitated patients, which was described as more challenging when fatigued. In such cases, decisions were postponed or delegated to others, especially towards the end of shifts. No one really wants to take responsibility for it because it’s a lot of work. I think many people don’t even see it as a matter of responsibility; they just see it as creating a lot of extra work for whoever does it. (P11) Lack of Clear or Immediate Consequences of Non-Intervention When inaction carried no obvious short-term harm, DF more commonly and strongly influenced decision-making. For example, deferring ventilator weaning by several hours - or even a day - was perceived as clinically acceptable because it was not time-critical (P7). Minor diagnostic or therapeutic adjustments were often delayed in a similar way when consequences were diffuse, uncertain or long-term. In contrast, when the consequences of inaction were severe (e.g., risk of cardiac arrest), the influence of DF was commonly described as negligible. Yes, weaning someone off the ventilator is a process. And it’s not time-critical, it can easily take hours. Whether you reduce the oxygen supply three hours later, or lower the PEEP a bit later, is nothing that has to happen minute by minute, or even within the hour. (P11) Lack of Urgency Decisions perceived as non-urgent were frequently reported as showing lower priority when DF was present. Participants described small, accumulating non-urgent requests as stressful and annoying when there was simply no nerve left for them (P2). Such tasks were more likely to be postponed, handled superficially, or delegated. Their perceived insignificance, combined with mental fatigue, made even minor decisions feel disproportionately effortful, increasing the tendency to avoid or minimise engagement with them. That really stressed me out. And when all those little crap tasks come at you from every side - from other physicians, from the nurses - it gets even more stressful, because you just don’t have the nerves for it anymore, especially when none of it is actually urgent. (P2) Tasks perceived as unpleasant Finally, decisions associated with tasks viewed as irritating, bureaucratic or burdensome were particularly susceptible to DF. Participants reported forgetting and/or deferring documentation, administrative tasks or tedious follow-up actions when fatigued. Emotional aversion therefore interacted strongly with fatigue with DF being more pronounced when tasks were perceived as unpleasant, reinforcing avoidance behaviours. When I’m tired, I have no energy for bureaucratic stuff… it feels even more burdensome, so I postpone it, forget it or pass it on to someone else (P19) . 4 Discussion Decision-Making as a Core Professional Identity Our findings show that participants hold a generally positive attitude toward clinical decision-making. Decision processes are perceived as a central component of intensivists’ professional role and are described as expressions of medical expertise, responsibility, and sources of professional meaning and identity. At the same time, physicians reported that decision-making becomes increasingly burdensome when cognitive and physical resources are depleted. This was particularly evident after demanding workdays and in the context of an accumulation of numerous small, often administrative or repetitive decisions, which were frequently perceived as lacking meaningfulness, disruptive, or detached from direct patient benefit. Beyond a potential decline in decision quality over time, this process may also compromise job satisfaction and staff well-being. Previous studies have shown that experiencing meaningfulness in one’s work not only predicts job satisfaction (17) but also buffers the negative effects of work-related stress on overall life satisfaction (18). When this sense of meaningfulness is subjectively diminished, staff well-being may consequently be at risk. Therefore, establishing and maintaining conditions that enable clinicians to focus their cognitive resources on clinically meaningful decisions appears to be relevant not only for patient safety but also as a key determinant of staff well-being and the long-term sustainability of professional practice in intensive care medicine. Impairments and Errors in Decision Making and Team Dynamics under Decision Fatigue In our study, DF in intensive care practice was characterised by a progressive depletion of cognitive resources, resulting in reduced attention, slower information processing, and less precise execution of essential cognitive tasks. These findings both support existing research and align with Baumeister’s principles of self-control (3), while also providing insights into how DF might be understood within a broader clinical and cognitive context. Participants described decisions made in this depleted state as more impulsive, less deliberate, and more driven by gut feeling , which may be understood in the context of dual-process theories of judgement. According to Kahneman, decision-making operates through two interacting systems: System 1, which is fast, intuitive, and heuristic-based allowing rapid pattern recognition but prone to error and System 2, which is slower, analytic, and deliberate, but cognitively demanding (19). Subsequent work has expanded this framework, including Thompson et al.’s emphasis on metacognitive monitoring and the role of control processes (20), as well as Evans et al.’s proposal to conceptualise the systems in terms of different types of cognitive processes (21) while maintaining the core distinction between automatic and controlled processing. Behaviours reported by participants such as avoidance, decision delay, reduced empathy, and declines in communication quality may also reflect a greater reliance on System 1 under cognitive depletion. This strategy conserves mental effort but increases susceptibility to cognitive biases and context-insensitive decisions (22). Previous studies have demonstrated that the relative contribution of each system is influenced by situational factors (23). For example, Finucane et al. showed that under time pressure, individuals rely more heavily on emotional components of judgement, thereby favouring System 1 processing (24). Participants’ descriptions suggest that DF may similarly shift the balance toward System 1 reliance. This shift could explain the increased error rates observed under cognitive depletion, with omission bias and status quo bias among the most common manifestations. Avoidance or postponement of decisions - often through deferral to subsequent shifts and redistribution of responsibility - may delay patient care (25). These cognitive and decisional alterations were perceived to translate into tangible patient safety risks, including medication errors and incomplete information processing, ultimately contributing to faulty clinical decisions. Together, these findings highlight DF as a critical risk factor for adverse events in intensive care settings and the importance of introducing mitigation strategies. Examples include increasing awareness of DF and cognitive biases, strategically scheduling cognitively demanding tasks at the start of shifts or immediately after breaks (26), and improving task planning through the establishment of clear team roles, responsibilities, assigned tasks, and backup plans, thereby reducing stress and the need for ad hoc decision-making if the primary plan fails (27). Empowering nursing staff and junior doctors to make certain decisions autonomously may not only decrease the individual decision load but also enhance staff satisfaction. A Typology of Susceptibility to Decision Fatigue Our findings suggest that DF does not act as a global or uniform influence but instead disproportionately affects specific types of decisions. Participants indicated that certain decision characteristics may either protect against or amplify the effects of DF. This more differentiated perspective offers a novel interpretive lens for existing quantitative research and may help explain why some studies demonstrate an influence of DF on medical decision making, whereas others do not. The low vulnerability of emergency decisions is consistent with prior research showing that such decisions are typically guided by algorithms and embedded within well-structured workflows – conditions that participants described as stabilising and protective. In a study by Stecker et al. examining stroke alert activations, no association was found between potential fatigue and either thrombolytic administration rates or diagnostic accuracy (28). The authors concluded that clinical performance in this context remains stable despite prolonged work periods, supporting the notion that high-stakes emergencies characterised by clear procedures, high salience, and immediate consequences are largely protected from DF, not least because of the adrenaline kick experienced by the practitioners in emergency situations. A similar pattern emerges in ethically significant and high-consequence decisions. Interviewees described these decisions as being distributed across team members, revisited over time, and shaped by collective filtering of relevant information. Such structural and social buffering mechanisms are likely to contribute to their relative stability under conditions of fatigue. Consistent with this interpretation, studies examining associations between endoscopist fatigue or time of day and colonoscopic adenoma detection found no relationship between detection rates and either the timing of procedures or the number of prior cases performed (29–31). Decisions of this kind involve substantial ethical responsibility and quality standards, which may provide an additional protective layer against DF. In contrast, our results indicate that other types of decisions are particularly susceptible to DF. The decision characteristics identified by participants as vulnerable closely mirror those examined in prior empirical work that demonstrated significant fatigue-related effects. Hand hygiene compliance, for example, has been shown to decline over the course of a typical 12-hour shift (32), reflecting tasks with limited immediacy or perceptible consequences for patients and therefore greater susceptibility under fatigue. Similarly, response times to physiological monitor alarms slow with each successive hour of a nurse’s shift, likely reflecting cumulative physical and mental fatigue (33). In a telephone helpline setting, the likelihood of conservative management decisions increased with each consecutive call taken since the last rest break (34). The tendency to avoid cognitively demanding or aversive tasks is further supported by studies on radiology reporting, where decreasing report similarity over workdays and workweeks suggests deteriorating report quality under fatigue, particularly among residents (35). → insert Figure 1 here Figure 1 illustrates our typology of clinical decisions according to their susceptibility to DF, based on key decision characteristics identified in our interviews. Decisions that are cognitively demanding, lack immediacy or clear consequences, or are perceived as unpleasant appear particularly vulnerable, whereas urgent, high-stakes decisions embedded in structured workflows show relative resilience. This visualisation underscores our central finding that DF does not act uniformly but selectively affects specific types of clinical decisions. Strengths and Limitations of the Study This study provides a detailed insight into intensivists’ experiences of DF. Several limitations should be noted: it was conducted at a single centre, relied on self-reported interview data, and did not include direct observation of clinical decision-making. Furthermore, the study was not designed to compare experiences between professional roles. Despite these limitations, the findings offer valuable perspectives for future research and practical interventions. They may guide future research in the selection of decisions under investigation. Rather than treating DF as a generalised state, classifying concrete ICU decisions according to the characteristics identified here may help identify those most susceptible to its effects. Such a typology would also have practical relevance, enabling organisational and technical support measures to be targeted where they are likely to yield the greatest benefit. 5 Conclusion Clinical decision-making constitutes a core element of intensivists’ professional identity and a key source of meaning, yet it becomes increasingly burdensome under cumulative cognitive and physical depletion, with potential consequences for both staff well-being and the sustainability of intensive care practice. When DF manifests it can cause deteriorations in communication and team dynamics and become a risk factor for patient safety. Our findings indicate that DF does not exert a uniform effect across all clinical decisions but affects those characterised by low immediacy, limited perceived consequences, or high cognitive or emotional aversiveness more. In contrast, urgent, high-stakes, and ethically salient decisions embedded in structured workflows appear relatively resilient due to procedural, social, and contextual buffering mechanisms. Recognising decision-specific vulnerability may help inform future research and targeted strategies to support clinical decision-making in the ICU. Abbreviations DF Decision Fatigue ICU Intensive Care Unit Declarations Ethics Approval and Consent to Participate The Ethics Committee of the University of Regensburg (Universität Regensburg, Ethikkommission, 93040 Regensburg) issued a declaration of non-objection, confirming that formal ethical approval was not required in accordance with § 15 of the Professional Code of Conduct for Physicians in Bavaria. All participants provided written informed consent for the participation and the publication of pseudonymised information prior to participation. All methods were performed in accordance with guidelines, regulations and the Declaration of Helsinki. Consent for Publication Written informed consent for publication of anonymised data and interview excerpts was obtained from all participants. Availability of Data and Materials The datasets generated and/or analysed during the current study are not publicly available due to participant confidentiality but are available from the corresponding author on reasonable request. Competing Interest The authors declare no competing interests. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors’ Contributions LS and AL conceptualized the study and together with AH developed the interview guide. LS conducted the interviews and performed the initial coding. AH provided supervision and methodological support throughout the analysis. LS and AL drafted the manuscript. RK, JR, and VK supported the literature search and assisted with linguistic revision of the manuscript. MK and CK helped conceptualising the manuscript and assisted with linguistic revision. All authors contributed to interpreting the findings, critically revised the manuscript, and approved the final version. Acknowledgements The authors thank all the participants of our study. Furthermore, we thank Prof. Bernhard Graf and Dr. Alexander Dejaco for providing us with the time needed to conduct this study. We thank Scott Weingard for planting the seed in AL's head that developed into the idea to conduct research in this field many years ago with his Emcrit-Podcast. References Ofstad EH, Frich JC, Schei E, Frankel RM, Gulbrandsen P. What is a medical decision? A taxonomy based on physician statements in hospital encounters: a qualitative study. BMJ Open. 2016 Feb 11;6(2):e010098. 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Endoscopist fatigue estimates and colonoscopic adenoma detection in a large community-based setting. Gastrointestinal Endoscopy. 2017 Mar 1;85(3):601-610.e2. Leffler DA, Kheraj R, Bhansali A, Yamanaka H, Neeman N, Sheth S, et al. Adenoma detection rates vary minimally with time of day and case rank: a prospective study of 2139 first screening colonoscopies. Gastrointestinal Endoscopy. 2012 Mar 1;75(3):554-560.e1. Keswani RN, Gawron AJ, Cooper A, Liss DT. Procedure Delays and Time of Day Are Not Associated With Reductions in Quality of Screening Colonoscopies. Clinical Gastroenterology and Hepatology. 2016 May;14(5):723-728.e2. Dai H, Milkman KL, Hofmann DA, Staats BR. The impact of time at work and time off from work on rule compliance: The case of hand hygiene in health care. Journal of Applied Psychology. 2015;100(3):846–62. Bonafide CP, Localio AR, Holmes JH, Nadkarni VM, Stemler S, MacMurchy M, et al. Video Analysis of Factors Associated With Response Time to Physiologic Monitor Alarms in a Children’s Hospital. JAMA Pediatr. 2017 June 1;171(6):524–31. Allan JL, Johnston DW, Powell DJH, Farquharson B, Jones MC, Leckie G, et al. Clinical decisions and time since rest break: An analysis of decision fatigue in nurses. Health Psychol. 2019 Apr;38(4):318–24. Vosshenrich J, Brantner P, Cyriac J, Boll DT, Merkle EM, Heye T. Quantifying Radiology Resident Fatigue: Analysis of Preliminary Reports. Radiology. 2021 Mar;298(3):632–9. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 29 Apr, 2026 Reviews received at journal 24 Apr, 2026 Reviews received at journal 09 Apr, 2026 Reviewers agreed at journal 31 Mar, 2026 Reviewers agreed at journal 30 Mar, 2026 Reviewers invited by journal 29 Mar, 2026 Editor assigned by journal 29 Mar, 2026 Editor invited by journal 13 Feb, 2026 Submission checks completed at journal 10 Feb, 2026 First submitted to journal 10 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8797546","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":615301647,"identity":"62d2da6a-6d80-45e6-bfe3-c3f3f0923f68","order_by":0,"name":"Lorenz Schiessl","email":"","orcid":"","institution":"University Hospital Regensburg","correspondingAuthor":false,"prefix":"","firstName":"Lorenz","middleName":"","lastName":"Schiessl","suffix":""},{"id":615301648,"identity":"b553a94d-8df9-46a8-9ac2-87ae9840920d","order_by":1,"name":"Anne Herrmann-Johns","email":"","orcid":"","institution":"University Hospital Regensburg","correspondingAuthor":false,"prefix":"","firstName":"Anne","middleName":"","lastName":"Herrmann-Johns","suffix":""},{"id":615301649,"identity":"7e20dd2f-da35-4f70-a244-76dde00fb3d9","order_by":2,"name":"Richard-Felix Kraus","email":"","orcid":"","institution":"University Hospital Regensburg","correspondingAuthor":false,"prefix":"","firstName":"Richard-Felix","middleName":"","lastName":"Kraus","suffix":""},{"id":615301650,"identity":"7e9c0f5d-8f1c-48c6-9fbd-08f19bb9bb1d","order_by":3,"name":"Viktoria Kimmerling","email":"","orcid":"","institution":"University Hospital Regensburg","correspondingAuthor":false,"prefix":"","firstName":"Viktoria","middleName":"","lastName":"Kimmerling","suffix":""},{"id":615301652,"identity":"dfc67523-fb96-470e-a630-d76bd6720ca0","order_by":4,"name":"Johanna Rosenberger","email":"","orcid":"","institution":"University Hospital Regensburg","correspondingAuthor":false,"prefix":"","firstName":"Johanna","middleName":"","lastName":"Rosenberger","suffix":""},{"id":615301654,"identity":"9cf1291f-7f71-48ed-aef8-9c5534ea0e25","order_by":5,"name":"Cynthia Kohl","email":"","orcid":"","institution":"University Hospital Regensburg","correspondingAuthor":false,"prefix":"","firstName":"Cynthia","middleName":"","lastName":"Kohl","suffix":""},{"id":615301655,"identity":"84cde35a-4e76-4adf-a0bb-dac4d62b4777","order_by":6,"name":"Martin Kees","email":"","orcid":"","institution":"University Hospital Regensburg","correspondingAuthor":false,"prefix":"","firstName":"Martin","middleName":"","lastName":"Kees","suffix":""},{"id":615301657,"identity":"7fc0fa87-222e-4658-a0c1-7aee857bd15f","order_by":7,"name":"Alexander Leonhard Leibold","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBklEQVRIie2RMUsDMRTHXzhol9iuOah3XyEhg8P1w1wQeoubS7emBOLk3u/hcmOPB96SD9DiUhGcFHSzg2AapCAYxc0hP8gbAj/+788DSCT+I8Mws8PToDRMoNfZ50+E7DhJUCi49V8UclA29c/K2GS3bN9WxZkmy919O6Wj7ZOUc6iKmMJwcC6uXSMna2K4cjOa311I5aCR0RikYndiUa2AWKYsUu6VTgP6Xt9T4vile7e48MrVW1C2LiiLmMKRkgefUjOfAkHZUOkTsI7tJXAg5altxCojhoUubnYpNG9ELKXozWP+bKuSDU33um+nxajHm1zPqzJa/8jXQ/DfhUQikUjE+QCFHFTSbg/VcgAAAABJRU5ErkJggg==","orcid":"","institution":"University Hospital Regensburg","correspondingAuthor":true,"prefix":"","firstName":"Alexander","middleName":"Leonhard","lastName":"Leibold","suffix":""}],"badges":[],"createdAt":"2026-02-05 13:23:54","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8797546/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8797546/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106001194,"identity":"c3b86c8b-582a-4363-9e66-7686db4cf3db","added_by":"auto","created_at":"2026-04-02 10:01:17","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":166200,"visible":true,"origin":"","legend":"\u003cp\u003eConceptual visualization of clinical decision characteristics associated with susceptibility to decision fatigue. Two clinical examples are shown for illustrative purposes only. The visualization is not based on quantitative measurements and does not represent absolute or comparative effect sizes.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8797546/v1/701c953ea83e89aa50311d40.png"},{"id":106094957,"identity":"7a8b7417-0972-4fbc-a060-662b0d248570","added_by":"auto","created_at":"2026-04-03 11:43:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1029695,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8797546/v1/5a3870f9-6dea-4029-a585-c79f42311fc1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Decision Fatigue in the ICU: Physician’s Perspectives and a Typology of Fatigue-Prone Decisions – A Qualitative Interview Study","fulltext":[{"header":"1 Background","content":"\u003cp\u003eMaking decisions is an essential part of medical practice, whether it involves prescribing medication, evaluating diagnostic information, or performing administrative tasks (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). A study by Ofstad et al. showed that physicians make an average of 13 clinical decisions per patient contact (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). According to Baumeister\u0026rsquo;s resource model of self-regulation, each decision draws on a limited cognitive resource (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). When numerous decisions must be made within a short period, these resources become depleted, leading to a gradual decline in the ability to make high-quality decisions (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). As work periods lengthen, individuals tend to make decisions less carefully and rely more heavily on cognitive shortcuts (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), for example by choosing less effortful or seemingly \u0026ldquo;safe\u0026rdquo; options such as postponing decisions or adhering more rigidly to guidelines. This phenomenon is called decision fatigue (DF).\u003c/p\u003e \u003cp\u003eResearch outside medicine illustrates similar patterns. In a well-known study, Danziger et al. found that judges became increasingly restrictive in their probation decisions as the working day progressed (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). In another study credit officers showed a decline in loan approvals during midday and late afternoon hours (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). These findings suggest that DF may influence decision-making across various professional domains.\u003c/p\u003e \u003cp\u003eComparable trends have been observed in clinical work. Studies have demonstrated an increase in the prescription of opioids (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) and antibiotics for acute respiratory infections (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) over the course of the day, and surgeons were less likely to perform surgical procedures toward the end of a shift (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). These examples point to potential fatigue-related shifts in clinical decision-making.\u003c/p\u003e \u003cp\u003eHowever, not all studies have identified such effects. A recent review found that, among 82 included studies, only 45% of those quantitatively assessing DF reported significant associations with diagnoses, test ordering, prescribing, or therapeutic decisions (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). With only one qualitative study identified, the review highlighted a lack of qualitative evidence, limiting insight into how DF is perceived and managed in everyday clinical practice. The authors concluded that qualitative approaches are needed to provide a more nuanced understanding of DF and to inform the development of targeted interventions (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDecision-making in clinical settings is complex and multifactorial. Intensive care units represent an environment that may be particularly susceptible to DF. Due to the patients\u0026rsquo; critical condition, even minor decisions have the potential to bear severe consequences, and directly life-threatening situations can arise any time. To deepen understanding of how ICU physicians perceive DF and its contextual influences, we conducted interviews with 19 intensivists to explore their experiences and to identify opportunities for prevention and better management of DF.\u003c/p\u003e"},{"header":"2 Methods","content":"\u003ch2\u003e2.1 \u0026nbsp; \u0026nbsp; Study Design\u003c/h2\u003e\n\u003cp\u003eA qualitative study design using semi-structured interviews was chosen to gain in-depth insights into physicians\u0026rsquo; experiences with DF. The interview guide based on an extensive literature review and was developed by an interdisciplinary research team involving physicians and health service researchers. It was pilot tested with two intensive care physicians who were not included in the final sample, and minor adjustments were made prior to data collection. The guide was iteratively refined throughout the interview process to incorporate emerging insights from the data.\u003c/p\u003e\n\u003ch2\u003e2.2 \u0026nbsp; \u0026nbsp; Participants and Recruitment\u003c/h2\u003e\n\u003cp\u003eThe Ethics Committee of the University of Regensburg issued a declaration of non-objection, confirming that formal ethical approval was not required in accordance with \u0026sect; 15 of the Professional Code of Conduct for Physicians in Bavaria. All methods were performed in accordance with relevant guidelines and regulations and in accordance with the Declaration of Helsinki. Recruitment was carried out through purposive sampling (12) among intensivists of our Department of Anaesthesiology, which runs three surgical ICUs. In order to capture a broad spectrum of different levels of clinical practice and corresponding decision-making experiences and perspectives, junior doctors within their first year of intensive care training, board certified anaesthetists during their specialization in intensive care and finally senior specialists with several years of specialization were invited via email. No incentives were provided. Participants received written and oral study information by the research team. All participants were adults and were provided written informed consent for the participation and the publication of pseudonymised information prior to participation. Nineteen physicians participated in the study, and their demographic characteristics are presented in Table 1.\u003c/p\u003e\n\u003ch2\u003e2.3 \u0026nbsp; \u0026nbsp; Data Collection\u003c/h2\u003e\n\u003cp\u003eThe interviews were conducted in person by LS between October 2024 and March 2025. They took place during regular working hours in a meeting room at the respective ward to facilitate participation. All interviews were audio recorded using Audacity (13) and pseudonymised before being transcribed verbatim using the transcription function of Microsoft Word 365 (14).\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e2.4 \u0026nbsp; \u0026nbsp; Data Analysis\u003c/h2\u003e\n\u003cp\u003eAn inductive approach based on the principles of the framework analysis was used to evaluate the interview data (15). Transcripts were read multiple times to familiarise with the data. Subsequently, meaning units were identified, openly coded, and systematically categorised. Data analysis was supported by MAXQDA software (16), enabling structured organization and management of the data. The first three transcripts were independently coded by two researchers (LS and AL) to ensure the reliability and consistency of the coding process. Any differences in coding were discussed and resolved by consensus.\u003c/p\u003e\n\u003cp\u003eAs the analysis progressed, codes were continuously compared, refined, and grouped into higher-level categories. AH provided ongoing supervision and methodological reflection throughout the entire process. Data analysis continued until theoretical saturation was reached, defined as the point at which no new relevant concepts emerged after coding three consecutive interviews (12).\u003c/p\u003e\n\u003cp\u003e\u0026rarr; insert Table 1 here\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003eDemographic data for participants\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"603\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipant\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClinical role\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExperience working on ICU (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 159px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eP1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003econsultant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e1-5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eP2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003econsultant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026gt; 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eP3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003econsultant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026gt; 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eP4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003econsultant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026gt; 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eP5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003econsultant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026gt; 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eP6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003econsultant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026gt; 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eP7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eresident\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e1-5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eP8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eresident\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e1-5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eP9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eresident\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026le; 0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eP10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eresident\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e1-5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eP11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eresident\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026le; 0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eP12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eresident\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e1-5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eP13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eresident\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e1-5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eP14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eresident\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e1-5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eP15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eresident\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e0.5-1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eP16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eresident\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e0.5-1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eP17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eresident\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e1-5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eP18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eresident\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026le; 0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eP19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eresident\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e0.5-1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 159px;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"3 Results","content":"\u003cp\u003eThe interviewees comprised 13 residents and board-certified specialists in executing roles, and 6 consultants with supervisory and treatment-planning responsibilities from three different ICUs of a university hospital. The length of the interviews varied from 22\u0026ndash;57 minutes and the IQR was 30.5 minutes. Analysis of the data revealed three major themes, which are described in detail below.\u003c/p\u003e \u003cp\u003e \u003cb\u003eMental Exhaustion and Decision Fatigue play an important role in the ICU\u003c/b\u003e \u003c/p\u003e \u003cp\u003eMost participants reported experiencing mental or physical exhaustion during their shifts, closely linked to the \u003cem\u003esheer number of decisions\u003c/em\u003e (P12) made. Several described a gradual depletion of \u003cem\u003ecognitive energy\u003c/em\u003e (P15) over the course of a shift, particularly on days with dense sequences of clinical choices. The accumulation of numerous small and seemingly inconsequential decisions, such as whether a patient may take a sip of water, was perceived as unexpectedly draining and often more exhausting than a small number of major decisions, such as whether a patient should be intubated. Participants noted that DF manifested as a narrowing of mental bandwidth, with routine tasks requiring greater effort and previously straightforward decisions becoming disproportionately effortful. This was attributed to the progressive depletion of attentional and working-memory resources, which reduces the capacity to process information efficiently and increased reliance on low-effort cognitive strategies. The threshold at which DF became noticeable varied substantially between individuals. Rather than a clearly defined moment, participants described a gradual, often subtle onset that became apparent only once they felt mentally slowed or disproportionately strained by routine tasks. They felt that situational factors such as stable staffing levels, predictable workflows, or uninterrupted breaks could delay the emergence of DF, whereas poor physical condition, accumulated stress, or limited clinical experience tended to accelerate it.\u003c/p\u003e \u003cp\u003eAlthough most participants highlighted a link between decision load and fatigue, a few indicated that routine decisions \u003cem\u003eshould not impact fatigue or decision quality\u003c/em\u003e (P7), reflecting an ideal of cognitive efficiency. However, even they acknowledged that personal circumstances or external pressures occasionally reduced their capacity to handle decision-dense shifts.\u003c/p\u003e \u003cp\u003e \u003cem\u003eI think I have a certain number of decisions I can make per day and when I reach a certain moment, I just can\u0026rsquo;t go on anymore. (P18)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eThe more of these small decisions there are, the more tiring it is, the less motivated you are, the more you want to conserve yourself and avoid this irrelevant petty crap. (P8)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eDecision-Making as a Core Component of Professional Identity\u003c/b\u003e \u003c/p\u003e \u003cp\u003eParticipants described medical decision-making and the responsibility associated with it as central to their professional identity. Making decisions was not only perceived as an operational necessity but as a meaningful and defining aspect of their role as physicians.\u003c/p\u003e \u003cp\u003e \u003cem\u003eIt is my task to make decisions, to bring patients forward. A day without decisions feels like a day lost. (P5)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eI also have the expectation of myself, that I become more independent and am able to act on my own. That\u0026rsquo;s why I try to make as many decisions myself as possible. (P9)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eDecision Fatigue influences both the Decision-Making Process and the Outcomes of Decisions\u003c/b\u003e \u003c/p\u003e \u003cp\u003eParticipants reported that DF affected several cognitive and behavioural aspects of decision-making. Concentration commonly declined under high decision load, described as \u003cem\u003eslowing down, not considering certain aspects\u003c/em\u003e (P9), with earlier decisions being revised more frequently (P14). Many described increased reliance on heuristics: \u003cem\u003eWe\u0026rsquo;ve been doing it this way recently, so it\u0026rsquo;s probably fine. (P11\u003c/em\u003e), framed as low-effort strategies to conserve limited cognitive resources.\u003c/p\u003e \u003cp\u003eDF was also associated with greater error-proneness. Participants described re-reading documentation without processing it (P11) and making procedural inaccuracies - especially in medication prescription - despite best intentions, attributed to diminished \u003cem\u003ecognitive capacity rather than negligence\u003c/em\u003e (P15). Some became \u003cem\u003emore impulsive, less deliberate, more driven by gut feeling\u003c/em\u003e (P8), while others reported the opposite reaction: avoidance, delay, or passing decisions to the next shift. Increased irritability, reduced empathy, and a decline in communication quality were also noted. In particular, participants described that explanations to colleagues, patients and relatives became shorter, less nuanced, and less patient, which occasionally resulted in misunderstanding or dissatisfaction. Physical symptoms such as headaches, tension and general exhaustion further accompanied these experiences.\u003c/p\u003e \u003cp\u003e \u003cem\u003eSometimes in the evening, you sit in front of your computer, and you read the same sentence over and over again without even getting what it says. (P11)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eErrors happen, you are not as attentive when prescribing meds, well you are putting in effort but you\u0026rsquo;re just not that capable anymore and make hasty mistakes you wouldn\u0026rsquo;t if you were rested. (P15)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eI definitely tend to pass the decision on to someone else. That's just the way it is, to be honest, everyone has to admit that, because I think we all do that to some extent. (P13)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eYes, you\u0026rsquo;re definitely more impulsive, less thoughtful and you make more gut decisions, yes. (P8)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003ePhysicians indicate various Characteristics of Decisions in which the Effects of Decision Fatigue are more likely to occur.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eResults indicate that not all decisions were equally affected by DF. Participants identified specific decisional characteristics that either protected against or amplified the effects of DF.\u003c/p\u003e \u003cp\u003e \u003cb\u003eDecision Characteristics associated with lower Susceptibility to Decision Fatigue\u003c/b\u003e \u003c/p\u003e \u003cp\u003eEmergency situations were consistently described as relatively resistant to DF. Even when fatigued, physicians reported being \u003cem\u003eable to draw on professionalism and remaining concentration\u003c/em\u003e (P7) to act effectively. The presence of well-rehearsed algorithms provided some degree of cognitive scaffolding: \u003cem\u003eEmergencies follow fixed routines\u0026hellip; I can do that even when I\u0026rsquo;m exhausted because it\u0026rsquo;s automatic\u003c/em\u003e (P11; P14). Physicians emphasised that in emergencies, action is obligatory despite uncertainty: \u003cem\u003eYou might make a wrong decision but doing nothing isn\u0026rsquo;t an option\u003c/em\u003e (P11). They noted that while DF could emerge afterwards, it generally appeared to have limited impact during acute decision-making.\u003c/p\u003e \u003cp\u003eParticipants described ethically weighty or high-consequence decisions - such as withdrawing life-sustaining treatment, escalating treatment, or determining key diagnostic steps - as less affected by DF. These decisions were typically made collaboratively within a multidisciplinary team (P3, P6), reducing potential impacts of an individual\u0026rsquo;s DF. Furthermore, such decisions often evolved over days rather than minutes, allowing clinicians to verify information, revisit judgements with a rested mind, and distribute cognitive responsibility across the team.\u003c/p\u003e \u003cp\u003e \u003cb\u003eDecision Characteristics associated with higher Susceptibility to Decision Fatigue\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIn contrast, respondents highlighted that certain characteristics make decisions more susceptible to the effects of DF described above. These characteristics are outlined in the following sections.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePhysical Effort\u003c/b\u003e \u003c/p\u003e \u003cp\u003ePhysicians reported that decisions leading to physical action were more difficult to initiate when fatigued. For example, going to the bedside for a clinical reassessment was sometimes deferred if information could be obtained indirectly, e.g. from the digital patient chart. Physically demanding procedures - such as placing central venous catheters - were more likely to be postponed. One participant explained that when exhausted, they \u003cem\u003eweigh differently how urgent practical tasks are\u003c/em\u003e (P17), describing a higher threshold for initiating labour-intensive interventions.\u003c/p\u003e \u003cp\u003e \u003cem\u003eAnd if I ought to do something hands on, despite being completely beat, tired, exhausted, I can\u0026rsquo;t concentrate anymore, then I weigh up the urgency differently. (P17)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003ePotential Risks and need for further Actions by Physicians\u003c/b\u003e \u003c/p\u003e \u003cp\u003eSeveral physicians reported adopting more cautious, conservative decision tendencies when fatigued. One described being \u003cem\u003eless willing to take risks\u003c/em\u003e and favouring options with low potential for deterioration or subsequent workload (P10). Another participant stated: \u003cem\u003eIf I\u0026rsquo;m already tired, I\u0026rsquo;m more likely to choose the approach that won\u0026rsquo;t trigger a cascade of further decisions\u003c/em\u003e (P13). Maintaining the status quo was frequently preferred over proactive intervention when fatigue was pronounced.\u003c/p\u003e \u003cp\u003e \u003cem\u003eAnd when you\u0026rsquo;re already over your limit, you tend to go for the safer option - or the one that involves fewer decisions - simply because you no longer have the capacity for anything else. (P13)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eExtensive Cognitive and Time Demands\u003c/b\u003e \u003c/p\u003e \u003cp\u003eDecisions requiring substantial deliberation or prolonged execution were often deferred due to DF. Participants stated that, deciding whether to do certain tasks was not avoided due to responsibility, but simply because they represented \u003cem\u003ea lot of work\u003c/em\u003e (P11). This was particularly evident in dealing with awake, demanding or agitated patients, which was described as more challenging when fatigued. In such cases, decisions were postponed or delegated to others, especially towards the end of shifts.\u003c/p\u003e \u003cp\u003e \u003cem\u003eNo one really wants to take responsibility for it because it\u0026rsquo;s a lot of work. I think many people don\u0026rsquo;t even see it as a matter of responsibility; they just see it as creating a lot of extra work for whoever does it. (P11)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eLack of Clear or Immediate Consequences of Non-Intervention\u003c/b\u003e \u003c/p\u003e \u003cp\u003eWhen inaction carried no obvious short-term harm, DF more commonly and strongly influenced decision-making. For example, deferring ventilator weaning by several hours - or even a day - was perceived as clinically acceptable because it was \u003cem\u003enot time-critical\u003c/em\u003e (P7). Minor diagnostic or therapeutic adjustments were often delayed in a similar way when consequences were diffuse, uncertain or long-term. In contrast, when the consequences of inaction were severe (e.g., risk of cardiac arrest), the influence of DF was commonly described as negligible.\u003c/p\u003e \u003cp\u003e \u003cem\u003eYes, weaning someone off the ventilator is a process. And it\u0026rsquo;s not time-critical, it can easily take hours. Whether you reduce the oxygen supply three hours later, or lower the PEEP a bit later, is nothing that has to happen minute by minute, or even within the hour. (P11)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eLack of Urgency\u003c/b\u003e \u003c/p\u003e \u003cp\u003eDecisions perceived as non-urgent were frequently reported as showing lower priority when DF was present. Participants described small, accumulating non-urgent requests as \u003cem\u003estressful and annoying\u003c/em\u003e when there was \u003cem\u003esimply no nerve left for them (P2).\u003c/em\u003e Such tasks were more likely to be postponed, handled superficially, or delegated. Their perceived insignificance, combined with mental fatigue, made even minor decisions feel disproportionately effortful, increasing the tendency to avoid or minimise engagement with them.\u003c/p\u003e \u003cp\u003e \u003cem\u003eThat really stressed me out. And when all those little crap tasks come at you from every side - from other physicians, from the nurses - it gets even more stressful, because you just don\u0026rsquo;t have the nerves for it anymore, especially when none of it is actually urgent. (P2)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eTasks perceived as unpleasant\u003c/b\u003e \u003c/p\u003e \u003cp\u003eFinally, decisions associated with tasks viewed as irritating, bureaucratic or burdensome were particularly susceptible to DF. Participants reported forgetting and/or deferring documentation, administrative tasks or tedious follow-up actions when fatigued. Emotional aversion therefore interacted strongly with fatigue with DF being more pronounced when tasks were perceived as unpleasant, reinforcing avoidance behaviours.\u003c/p\u003e \u003cp\u003e \u003cem\u003eWhen I\u0026rsquo;m tired, I have no energy for bureaucratic stuff\u0026hellip; it feels even more burdensome, so I postpone it, forget it or pass it on to someone else (P19)\u003c/em\u003e.\u003c/p\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eDecision-Making as a Core Professional Identity\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur findings show that participants hold a generally positive attitude toward clinical decision-making. Decision processes are perceived as a central component of intensivists\u0026rsquo; professional role and are described as expressions of medical expertise, responsibility, and sources of professional meaning and identity.\u003c/p\u003e\n\u003cp\u003eAt the same time, physicians reported that decision-making becomes increasingly burdensome when cognitive and physical resources are depleted. This was particularly evident after demanding workdays and in the context of an accumulation of numerous small, often administrative or repetitive decisions, which were frequently perceived as lacking meaningfulness, disruptive, or detached from direct patient benefit.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBeyond a potential decline in decision quality over time, this process may also compromise job satisfaction and staff well-being. Previous studies have shown that experiencing meaningfulness in one\u0026rsquo;s work not only predicts job satisfaction (17) but also buffers the negative effects of work-related stress on overall life satisfaction (18). When this sense of meaningfulness is subjectively diminished, staff well-being may consequently be at risk.\u003c/p\u003e\n\u003cp\u003eTherefore, establishing and maintaining conditions that enable clinicians to focus their cognitive resources on clinically meaningful decisions appears to be relevant not only for patient safety but also as a key determinant of staff well-being and the long-term sustainability of professional practice in intensive care medicine.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eImpairments and Errors in Decision Making and Team Dynamics under Decision Fatigue\u003c/p\u003e\n\u003cp\u003eIn our study, DF in intensive care practice was characterised by a progressive depletion of cognitive resources, resulting in reduced attention, slower information processing, and less precise execution of essential cognitive tasks. These findings both support existing research and align with Baumeister\u0026rsquo;s principles of self-control \u0026nbsp;(3), while also providing insights into how DF might be understood within a broader clinical and cognitive context.\u003c/p\u003e\n\u003cp\u003eParticipants described decisions made in this depleted state as \u003cem\u003emore impulsive, less deliberate, and more driven by gut feeling\u003c/em\u003e, which may be understood in the context of dual-process theories of judgement. According to Kahneman, decision-making operates through two interacting systems: System 1, which is fast, intuitive, and heuristic-based allowing rapid pattern recognition but prone to error and System 2, which is slower, analytic, and deliberate, but cognitively demanding\u0026nbsp;(19).\u0026nbsp;Subsequent work has expanded this framework, including Thompson et al.\u0026rsquo;s emphasis on metacognitive monitoring and the role of control processes\u0026nbsp;(20),\u0026nbsp;as well as Evans et al.\u0026rsquo;s proposal to conceptualise the systems in terms of different types of cognitive processes\u0026nbsp;(21)\u0026nbsp;while maintaining the core distinction between automatic and controlled processing.\u003c/p\u003e\n\u003cp\u003eBehaviours reported by participants such as avoidance, decision delay, reduced empathy, and declines in communication quality may also reflect a greater reliance on System 1 under cognitive depletion. This strategy conserves mental effort but increases susceptibility to cognitive biases and context-insensitive decisions\u0026nbsp;(22).\u0026nbsp;Previous studies have demonstrated that the relative contribution of each system is influenced by situational factors\u0026nbsp;(23).\u0026nbsp;For example, Finucane et al. showed that under time pressure, individuals rely more heavily on emotional components of judgement, thereby favouring System 1 processing\u0026nbsp;(24).\u0026nbsp;Participants\u0026rsquo; descriptions suggest that DF may similarly shift the balance toward System 1 reliance.\u003c/p\u003e\n\u003cp\u003eThis shift could explain the increased error rates observed under cognitive depletion, with omission bias and status quo bias among the most common manifestations. Avoidance or postponement of decisions - often through deferral to subsequent shifts and redistribution of responsibility - may delay patient care (25). These cognitive and decisional alterations were perceived to translate into tangible patient safety risks, including medication errors and incomplete information processing, ultimately contributing to faulty clinical decisions. Together, these findings highlight DF as a critical risk factor for adverse events in intensive care settings and the importance of introducing mitigation strategies. Examples include increasing awareness of DF and cognitive biases, strategically scheduling cognitively demanding tasks at the start of shifts or immediately after breaks (26), and improving task planning through the establishment of clear team roles, responsibilities, assigned tasks, and backup plans, thereby reducing stress and the need for ad hoc decision-making if the primary plan fails (27). Empowering nursing staff and junior doctors to make certain decisions autonomously may not only decrease the individual decision load but also enhance staff satisfaction.\u003c/p\u003e\n\u003cp\u003eA Typology of Susceptibility to Decision Fatigue\u003c/p\u003e\n\u003cp\u003eOur findings suggest that DF does not act as a global or uniform influence but instead disproportionately affects specific types of decisions. Participants indicated that certain decision characteristics may either protect against or amplify the effects of DF. This more differentiated perspective offers a novel interpretive lens for existing quantitative research and may help explain why some studies demonstrate an influence of DF on medical decision making, whereas others do not.\u003c/p\u003e\n\u003cp\u003eThe low vulnerability of emergency decisions is consistent with prior research showing that such decisions are typically guided by algorithms and embedded within well-structured workflows \u0026ndash; conditions that participants described as stabilising and protective. In a study by Stecker et al. examining stroke alert activations, no association was found between potential fatigue and either thrombolytic administration rates or diagnostic accuracy (28). The authors concluded that clinical performance in this context remains stable despite prolonged work periods, supporting the notion that high-stakes emergencies characterised by clear procedures, high salience, and immediate consequences are largely protected from DF, not least because of the adrenaline kick experienced by the practitioners in emergency situations.\u003c/p\u003e\n\u003cp\u003eA similar pattern emerges in ethically significant and high-consequence decisions. Interviewees described these decisions as being distributed across team members, revisited over time, and shaped by collective filtering of relevant information. Such structural and social buffering mechanisms are likely to contribute to their relative stability under conditions of fatigue. Consistent with this interpretation, studies examining associations between endoscopist fatigue or time of day and colonoscopic adenoma detection found no relationship between detection rates and either the timing of procedures or the number of prior cases performed\u0026nbsp;(29\u0026ndash;31). Decisions of this kind involve substantial ethical responsibility and quality standards, which may provide an additional protective layer against DF.\u003c/p\u003e\n\u003cp\u003eIn contrast, our results indicate that other types of decisions are particularly susceptible to DF. The decision characteristics identified by participants as vulnerable closely mirror those examined in prior empirical work that demonstrated significant fatigue-related effects. Hand hygiene compliance, for example, has been shown to decline over the course of a typical 12-hour shift (32), reflecting tasks with limited immediacy or perceptible consequences for patients and therefore greater susceptibility under fatigue. Similarly, response times to physiological monitor alarms slow with each successive hour of a nurse\u0026rsquo;s shift, likely reflecting cumulative physical and mental fatigue (33). In a telephone helpline setting, the likelihood of conservative management decisions increased with each consecutive call taken since the last rest break (34). The tendency to avoid cognitively demanding or aversive tasks is further supported by studies on radiology reporting, where decreasing report similarity over workdays and workweeks suggests deteriorating report quality under fatigue, particularly among residents (35).\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"text-align: start;color: rgb(0, 0, 0);background-color: rgb(255, 255, 255);font-size: 11px;font-family: Verdana, Arial, Helvetica, sans-serif;\"\u003e\u0026rarr;\u003c/span\u003e insert Figure 1 here\u003c/p\u003e\n\u003cp\u003eFigure 1 illustrates our typology of clinical decisions according to their susceptibility to DF, based on key decision characteristics identified in our interviews. Decisions that are cognitively demanding, lack immediacy or clear consequences, or are perceived as unpleasant appear particularly vulnerable, whereas urgent, high-stakes decisions embedded in structured workflows show relative resilience. This visualisation underscores our central finding that DF does not act uniformly but selectively affects specific types of clinical decisions.\u003c/p\u003e\n\u003cp\u003eStrengths and Limitations of the Study\u003c/p\u003e\n\u003cp\u003eThis study provides a detailed insight into intensivists\u0026rsquo; experiences of DF. Several limitations should be noted: it was conducted at a single centre, relied on self-reported interview data, and did not include direct observation of clinical decision-making. Furthermore, the study was not designed to compare experiences between professional roles. Despite these limitations, the findings offer valuable perspectives for future research and practical interventions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThey may guide future research in the selection of decisions under investigation. Rather than treating DF as a generalised state, classifying concrete ICU decisions according to the characteristics identified here may help identify those most susceptible to its effects. Such a typology would also have practical relevance, enabling organisational and technical support measures to be targeted where they are likely to yield the greatest benefit.\u003c/p\u003e"},{"header":"5 Conclusion","content":"\u003cp\u003eClinical decision-making constitutes a core element of intensivists\u0026rsquo; professional identity and a key source of meaning, yet it becomes increasingly burdensome under cumulative cognitive and physical depletion, with potential consequences for both staff well-being and the sustainability of intensive care practice. When DF manifests it can cause deteriorations in communication and team dynamics and become a risk factor for patient safety.\u003c/p\u003e \u003cp\u003eOur findings indicate that DF does not exert a uniform effect across all clinical decisions but affects those characterised by low immediacy, limited perceived consequences, or high cognitive or emotional aversiveness more. In contrast, urgent, high-stakes, and ethically salient decisions embedded in structured workflows appear relatively resilient due to procedural, social, and contextual buffering mechanisms. Recognising decision-specific vulnerability may help inform future research and targeted strategies to support clinical decision-making in the ICU.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDecision Fatigue\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eICU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIntensive Care Unit\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Ethics Committee of the University of Regensburg (Universit\u0026auml;t Regensburg, Ethikkommission, 93040 Regensburg) issued a declaration of non-objection, confirming that formal ethical approval was not required in accordance with \u0026sect; 15 of the Professional Code of Conduct for Physicians in Bavaria. All participants provided written informed consent for the participation and the publication of pseudonymised information prior to participation. All methods were performed in accordance with guidelines, regulations and the Declaration of Helsinki.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication of anonymised data and interview excerpts was obtained from all participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available due to participant confidentiality but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interest\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLS and AL conceptualized the study and together with AH developed the interview guide. LS conducted the interviews and performed the initial coding. AH provided supervision and methodological support throughout the analysis. LS and AL drafted the manuscript. RK, JR, and VK supported the literature search and assisted with linguistic revision of the manuscript. MK and CK helped conceptualising the manuscript and assisted with linguistic revision. \u0026nbsp;All authors contributed to interpreting the findings, critically revised the manuscript, and approved the final version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank all the participants of our study. \u0026nbsp;Furthermore, we thank Prof. Bernhard Graf and Dr. Alexander Dejaco for providing us with the time needed to conduct this study. We thank Scott Weingard for planting the seed in AL\u0026apos;s head that developed into the idea to conduct research in this field many years ago with his Emcrit-Podcast.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eOfstad EH, Frich JC, Schei E, Frankel RM, Gulbrandsen P. What is a medical decision? A taxonomy based on physician statements in hospital encounters: a qualitative study. BMJ Open. 2016 Feb 11;6(2):e010098.\u003c/li\u003e\n \u003cli\u003eOfstad EH, Frich JC, Schei E, Frankel RM, \u0026Scaron;altytė Benth J, Gulbrandsen P. Clinical decisions presented to patients in hospital encounters: a cross-sectional study using a novel taxonomy. BMJ Open. 2018 Jan 5;8(1):e018042.\u003c/li\u003e\n \u003cli\u003eBaumeister RF, Bratslavsky E, Muraven M, Tice DM. Ego depletion: Is the active self a limited resource? Journal of Personality and Social Psychology. 1998;74(5):1252\u0026ndash;65.\u003c/li\u003e\n \u003cli\u003eSchweitzer DR, Baumeister R, Laakso EL, Ting J. Self-control, limited willpower and decision fatigue in healthcare settings. Intern Med J. 2023 June;53(6):1076\u0026ndash;80.\u003c/li\u003e\n \u003cli\u003ePignatiello GA, Martin RJ, Hickman RL. Decision fatigue: A conceptual analysis. J Health Psychol. 2020 Jan;25(1):123\u0026ndash;35.\u003c/li\u003e\n \u003cli\u003eDanziger S, Levav J, Avnaim-Pesso L. Extraneous factors in judicial decisions. Proc Natl Acad Sci U S A. 2011 Apr 26;108(17):6889\u0026ndash;92.\u003c/li\u003e\n \u003cli\u003eBaer T, Schnall S. Quantifying the cost of decision fatigue: suboptimal risk decisions in finance. R Soc Open Sci. 2021 May 5;8(5):201059.\u003c/li\u003e\n \u003cli\u003eHughes J, Lysikowski J, Acharya R, Phelps E, Kandil E. A Multi-year Analysis of Decision Fatigue in Opioid Prescribing. 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Berlin, Heidelberg: Springer; 2010 [cited 2025 Sept 21]. p. 183\u0026ndash;212. Available from: https://doi.org/10.1007/978-3-540-95936-6_5\u003c/li\u003e\n \u003cli\u003eAudacity Team. Audacity [computer program]. Version 3.3.2. Manchester (UK): Audacity Team; 2023 [cited 2025 Sep 22]. Available from: https://www.audacityteam.org/.\u003c/li\u003e\n \u003cli\u003eMicrosoft Corporation. Microsoft Word for Microsoft 365 [computer program]. Redmond (WA): Microsoft Corporation; 2021 [cited 2025 Sep 21]. Available from: https://www.microsoft.com/.\u003c/li\u003e\n \u003cli\u003eGale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013 Sept 18;13(1):117.\u003c/li\u003e\n \u003cli\u003eMAXQDA, Software f\u0026uuml;r qualitative Datenanalyse, 1989 \u0026ndash; 2025, VERBI Software. Consult. 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Perspect Psychol Sci. 2013 May 1;8(3):223\u0026ndash;41.\u003c/li\u003e\n \u003cli\u003eLighthall GK, Vazquez-Guillamet C. Understanding Decision Making in Critical Care. Clin Med Res. 2015 Dec;13(3\u0026ndash;4):156\u0026ndash;68.\u003c/li\u003e\n \u003cli\u003eHochman G. Beyond the Surface: A New Perspective on Dual-System Theories in Decision-Making. Behavioral Sciences. 2024 Nov;14(11):1028.\u003c/li\u003e\n \u003cli\u003eFinucane ML, Alhakami A, Slovic P, Johnson SM. The affect heuristic in judgments of risks and benefits. Journal of Behavioral Decision Making. 2000;13(1):1\u0026ndash;17.\u003c/li\u003e\n \u003cli\u003eBeldhuis IE, Marapin RS, Jiang YY, Sim\u0026otilde;es de Souza NF, Georgiou A, Kaufmann T, et al. Cognitive biases, environmental, patient and personal factors associated with critical care decision making: A scoping review. Journal of Critical Care. 2021 Aug 1;64:144\u0026ndash;53.\u003c/li\u003e\n \u003cli\u003eChoudhury NA, Saravanan P. An integrative review on unveiling the causes and effects of decision fatigue to develop a multi-domain conceptual framework. Front Cognit [Internet]. 2026 Jan 9 [cited 2026 Jan 19];4. Available from: https://www.frontiersin.org/journals/cognition/articles/10.3389/fcogn.2025.1719312/full\u003c/li\u003e\n \u003cli\u003eJanhofer DE, Lakhiani C, Song DH. Addressing Surgeon Fatigue: Current Understanding and Strategies for Mitigation. Plast Reconstr Surg. 2019 Oct;144(4):693e\u0026ndash;9e.\u003c/li\u003e\n \u003cli\u003eStecker M, Michel K, Antaky K, Wolin A, Koyfman F. Characteristics of the stroke alert process in a general Hospital. Surg Neurol Int. 2015;6(1):5.\u003c/li\u003e\n \u003cli\u003eLee A, Jensen CD, Marks AR, Zhao WK, Doubeni CA, Zauber AG, et al. Endoscopist fatigue estimates and colonoscopic adenoma detection in a large community-based setting. Gastrointestinal Endoscopy. 2017 Mar 1;85(3):601-610.e2.\u003c/li\u003e\n \u003cli\u003eLeffler DA, Kheraj R, Bhansali A, Yamanaka H, Neeman N, Sheth S, et al. Adenoma detection rates vary minimally with time of day and case rank: a prospective study of 2139 first screening colonoscopies. Gastrointestinal Endoscopy. 2012 Mar 1;75(3):554-560.e1.\u003c/li\u003e\n \u003cli\u003eKeswani RN, Gawron AJ, Cooper A, Liss DT. Procedure Delays and Time of Day Are Not Associated With Reductions in Quality of Screening Colonoscopies. Clinical Gastroenterology and Hepatology. 2016 May;14(5):723-728.e2.\u003c/li\u003e\n \u003cli\u003eDai H, Milkman KL, Hofmann DA, Staats BR. The impact of time at work and time off from work on rule compliance: The case of hand hygiene in health care. Journal of Applied Psychology. 2015;100(3):846\u0026ndash;62.\u003c/li\u003e\n \u003cli\u003eBonafide CP, Localio AR, Holmes JH, Nadkarni VM, Stemler S, MacMurchy M, et al. Video Analysis of Factors Associated With Response Time to Physiologic Monitor Alarms in a Children\u0026rsquo;s Hospital. JAMA Pediatr. 2017 June 1;171(6):524\u0026ndash;31.\u003c/li\u003e\n \u003cli\u003eAllan JL, Johnston DW, Powell DJH, Farquharson B, Jones MC, Leckie G, et al. Clinical decisions and time since rest break: An analysis of decision fatigue in nurses. Health Psychol. 2019 Apr;38(4):318\u0026ndash;24.\u003c/li\u003e\n \u003cli\u003eVosshenrich J, Brantner P, Cyriac J, Boll DT, Merkle EM, Heye T. Quantifying Radiology Resident Fatigue: Analysis of Preliminary Reports. Radiology. 2021 Mar;298(3):632\u0026ndash;9.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"decision fatigue, patient safety, staff wellbeing, clinical decision making, intensive care unit, semi-structured interview, qualitative research","lastPublishedDoi":"10.21203/rs.3.rs-8797546/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8797546/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e The concept of Decision fatigue (DF) originates from research in social psychology and refers to a state of cognitive and self-regulatory exhaustion consequential to repeated decision making. It is assumed that making decisions consumes a limited resource of mental energy which can impair the quality of subsequent decisions. As this resource is depleted, the ability to exercise self-control declines, which can lead to less considered, more impulsive decisions or even no decision at all. Although the concept of DF has been acknowledged over many areas, previous studies in the medical context have shown inconclusive results. This study explored intensive care physicians’ views and experiences on DF and its potential impact on medical decision making in the intensive care unit (ICU).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e 19 semi-structured interviews were conducted in person with ICU physicians from October 2024 to March 2025. All interviews were audio-recorded, transcribed verbatim, and analysed using the framework method until data saturation was achieved.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003e19 physicians from three different ICUs participated, including 13 residents and board-certified specialists in executing roles and 6 consultants with supervisory and treatment-planning responsibilities. Three major themes were identified and developed: (1) DF and mental exhaustion occur in the ICU; (2) DF influences both the decision-making process and the outcome of decisions; and (3) physicians indicate various characteristics of decisions in which the effects of DF are more likely to occur.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e This study provides new insights into ICU physicians’ experiences of DF. \u0026nbsp;Understanding which decisions are most vulnerable to DF may help guide future research and interventions to support clinical decision-making.\u003c/p\u003e","manuscriptTitle":"Decision Fatigue in the ICU: Physician’s Perspectives and a Typology of Fatigue-Prone Decisions – A Qualitative Interview Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-02 10:01:13","doi":"10.21203/rs.3.rs-8797546/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-29T04:35:02+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-24T13:16:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-09T11:54:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"314307689009335102827254174849278967912","date":"2026-03-31T12:58:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"125187520395479902465535033225636028649","date":"2026-03-30T09:39:08+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-29T06:31:40+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-29T06:26:53+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-13T05:27:06+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-10T13:30:43+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2026-02-10T12:33:22+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1dd492dd-7b04-4326-806d-44b824bfc777","owner":[],"postedDate":"April 2nd, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-04-29T04:35:02+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":65470191,"name":"Health sciences/Health care"},{"id":65470192,"name":"Health sciences/Medical research"},{"id":65470193,"name":"Biological sciences/Psychology"},{"id":65470194,"name":"Social science/Psychology"}],"tags":[],"updatedAt":"2026-05-13T00:53:17+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-02 10:01:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8797546","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8797546","identity":"rs-8797546","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}