Introduction

Emergency medicine is a field of rapid decision-making, where doctors and nurses must assess, diagnose, and treat critically ill patients within minutes. Every shift in the Emergency Department (ED) involves constant prioritisation, risk assessment, and complex clinical judgement under time pressure. While this 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 8, 10, 12, or even 14 hours straight in a crowded ED. By the end of a shift, even the most experienced Emergency Medicine clinicians can struggle with mental exhaustion. For trainees preparing for MRCEM or FRCEM, understanding decision fatigue is just as important as revising ECGs or trauma protocols. But how does decision fatigue impact patient care, and what practical steps can we take to mitigate it in real-world Emergency Medicine practice?

What Is Decision Fatigue?

Decision fatigue refers to the deteriorating quality of decisions after a prolonged period of decision-making. The more choices we make, the harder each one becomes, and the more likely we are to default to easier, quicker, or more defensive options. 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 for patient safety, clinical governance, and team performance.

For ED doctors and nurses, decision fatigue is not a theoretical concept; it is experienced at 03:00 on night four, in the last hour of a long day in Majors, or after back-to-back resus calls. It can subtly affect every aspect of care: from how thoroughly you safety-net a patient with chest pain, to whether you challenge an ambiguous CT report, to whether you call for senior help one hour earlier or one hour too late.

Signs of Decision Fatigue in Emergency Medicine

Decision fatigue rarely announces itself loudly. Instead, it creeps into routine ED work as small shifts in behaviour and judgement. Common signs include:

• Delayed or Avoidant Decision-Making – Taking longer to act, even in critical situations. The clinician “parks” decisions, reviews the same patient multiple times, or repeatedly defers disposition choices (admit vs discharge).
• Cognitive Biases – Relying on shortcuts (heuristics) instead of thorough clinical reasoning. For example, anchoring on the triage diagnosis, or assuming a frequent attender is “just anxiety” without revisiting red flags.
• Increased Errors – Fatigue can lead to mistakes in prescribing, interpreting investigations, or diagnosing. Dose calculations, ECG interpretation, and subtle X-ray findings are particularly vulnerable.
• Emotional Detachment – A subtle shift from patient-centred care to autopilot mode. Interactions become transactional, empathy decreases, and the team can feel more irritable or withdrawn.
• Over-Reliance on “Default” Options – Automatically choosing “admit,” “discharge with safety-netting,” or “CT just in case” rather than individualised decision-making.

The Science Behind It

Research in cognitive psychology and clinical decision-making shows that as mental resources are depleted, the brain favours simpler, low-effort choices. In Emergency Medicine, this often translates into more conservative or more defensive behaviours, depending on context. For example:

• Increased Antibiotic Prescriptions – Studies indicate that as fatigue worsens across a clinic or ED session, doctors tend to prescribe antibiotics more frequently, even when they are not clearly indicated. Prescribing becomes the “path of least resistance.”
• Overuse of Imaging – Instead of taking time to clinically evaluate a patient, a tired clinician may order a CT scan “just in case” to reduce uncertainty. This can lead to unnecessary radiation exposure, increased cost, and incidental findings that complicate care.
• Defensive Medicine – As the shift progresses, clinicians may admit more patients rather than risk a missed diagnosis. This can contribute to ED crowding, exit block, and additional bed pressures.

For trainees revising for the MRCEM SBA or FRCEM SBA, this links directly to exam questions on human factors, patient safety, and clinical governance. Decision fatigue is not just a wellness issue — it is a safety-critical component of Emergency Medicine practice.

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 and “normal” initial observations. At the start of the shift, they might have explored risk factors thoroughly, reviewed ECGs carefully, and considered ACS decision tools in detail. Ten hours in, with multiple unresolved tasks and a full waiting room, their tired brain defaults to “low risk — discharge home with advice.”

Unfortunately, the patient later returns in cardiac arrest. In the subsequent M&M meeting, it becomes clear that this was not a knowledge gap; the clinician understood ACS management, had completed MRCEM revision on chest pain, and could quote the guidelines. The root cause was degraded decision-making under pressure and fatigue — exactly the scenario Emergency Medicine training must now address explicitly.

Strategies to Combat Decision Fatigue

We cannot remove complexity from Emergency Medicine, but we can design systems, habits, and learning strategies that protect decision-making under pressure. Key approaches include:

1. Cognitive Offloading

• Use clinical pathways, decision tools, and protocols to reduce unnecessary cognitive load. Examples include chest pain pathways, PE algorithms, and local sepsis bundles. These tools free up mental bandwidth for genuinely complex decisions.
• Standardised checklists (like the WHO surgical checklist, RSI checklist, or ED sepsis proforma) help maintain focus on safety-critical steps when the brain is tired.
• Incorporate structured approaches taught in Emergency Medicine online courses and OSCE training — for example, ABCDE, SBAR, and structured handover tools — so that good habits are automatic, even at the end of a long shift.

2. Strategic Breaks

• Even a five-minute pause away from the noise of the ED can help reset cognitive function. A brief walk, a drink of water, or a quiet moment to regroup can significantly improve subsequent decision-making.
• Hydration, nutrition, and short mental resets are not luxuries; they are safety interventions. Departments that protect break time often see better morale and fewer significant incidents.
• For trainees preparing for MRCEM and FRCEM, building self-awareness around fatigue and focus during revision can translate directly into safer practice in the ED.

3. Team-Based Decision-Making

• Encourage senior input when fatigued, especially for high-risk presentations such as chest pain, sepsis, safeguarding, or potential neurosurgical emergencies.
• Share cognitive load with colleagues: use board rounds, huddles, and resus debriefs to surface concerns early and collectively problem-solve.
• A strong Emergency Medicine team culture makes it normal to say, “I’m tired — can we go through this case together?” rather than silently carrying the risk alone.

4. Awareness & Self-Reflection

• Recognising fatigue is key — if you feel mentally drained, double-check high-risk decisions, re-read ECGs, and consider asking a colleague to review borderline cases.
• Encourage a culture where asking for a second opinion is seen as strength, not weakness. This aligns with good clinical governance and is often emphasised in Emergency Medicine exam preparation (MRCEM OSCE, FRCEM OSCE).
• Use reflection (e.g. learning logs, portfolio entries, or debriefs) to identify when decision fatigue influenced care and how you can modify systems and habits for next time.

Conclusion

Emergency Medicine is as much about endurance as it is about expertise. Decision fatigue is inevitable when working in a high-volume, high-acuity ED, but unmanaged it can erode safety, quality, and professional satisfaction. Recognising and managing decision fatigue is not just about protecting clinicians — it is about ensuring the best possible care for patients, shift after shift.

By combining structured cognitive tools, strategic breaks, supportive team culture, and reflective practice, we can make Emergency Medicine safer, smarter, and more sustainable. Whether you are an ED consultant leading clinical governance, or a trainee preparing for MRCEM and FRCEM with EM Learning Centre resources and other Emergency Medicine online courses, building resilience in decision-making is a core clinical skill.

Decision fatigue will always be part of the job — but it does not have to define the quality of our care.