Introduction

Emergency medicine is a field of rapid decision-making, where doctors and nurses must assess, diagnose, and treat critically ill patients within minutes. While the fast pace is part of the job’s appeal, it also comes with a hidden challenge—decision fatigue. 

Imagine making life-or-death choices for 10, 12, or even 14 hours straight. By the end of a shift, even the most experienced clinicians can struggle with mental exhaustion. But how does decision fatigue impact patient care, and what can we do about it?

What Is Decision Fatigue?

Decision fatigue refers to the deteriorating quality of decisions after a long session of decision-making. In emergency medicine, where clinicians may make hundreds of decisions per shift—ranging from minor medication adjustments to major resuscitation choices—this mental strain can have serious consequences.

Signs of Decision Fatigue in Emergency Medicine:

• Delayed or Avoidant Decision-Making – Taking longer to act, even in critical situations.
• Cognitive Biases – Relying on shortcuts (heuristics) instead of thorough clinical reasoning.
• Increased Errors – Fatigue can lead to mistakes in prescribing, interpreting investigations, or diagnosing.
• Emotional Detachment – A subtle shift from patient-centred care to autopilot mode. 

The Science Behind It

Research shows that as decision fatigue sets in, doctors are more likely to default to safer, easier choices. For example:

• Increased Antibiotic Prescriptions: Studies indicate that as fatigue worsens, doctors tend to prescribe antibiotics more frequently, even when unnecessary.
• Overuse of Imaging: Instead of taking time to clinically evaluate a patient, a tired clinician may order a CT scan “just in case.”
• Defensive Medicine: As the shift progresses, clinicians may admit more patients rather than risk a missed diagnosis.

The High-Stakes Impact in Emergency Medicine

Unlike other specialties, emergency medicine offers little downtime for reflection. Every minute presents a new challenge. This relentless demand can lead to burnout, lower job satisfaction, and, most importantly, compromised patient safety.

Real-Life Example:

Consider a busy Friday night in A&E. A junior doctor, after seeing 25 patients, is faced with a patient with vague chest pain. At the start of the shift, they might have thoroughly investigated the case. But now, 10 hours in, their tired brain defaults to “low risk—discharge home.” Unfortunately, the patient later returns in cardiac arrest. 

Strategies to Combat Decision Fatigue

1. Cognitive Offloading

• Use clinical pathways and protocols to reduce unnecessary decision-making.
• Standardised checklists (like the WHO surgical checklist) help maintain focus.

2. Strategic Breaks

• Even a five-minute pause can help reset cognitive function.
• Hydration, nutrition, and short mental resets improve decision-making.

3. Team-Based Decision-Making

• Encourage senior input when fatigued.
• Sharing cognitive load with colleagues can prevent mistakes.

4. Awareness & Self-Reflection

• Recognising fatigue is key—if you feel mentally drained, double-check high-risk decisions.
• Encourage a culture where asking for a second opinion is seen as strength, not weakness. 

Conclusion

Emergency medicine is as much about endurance as it is about expertise. Recognising and managing decision fatigue is not just about protecting clinicians—it’s about ensuring the best care for patients. By acknowledging its effects and implementing strategies to mitigate it, we can make emergency medicine safer, smarter, and more sustainable.