Intensive care physicians' experiences of decision fatigue and characteristics of vulnerable clinical decisions.

Decision fatigue (DF) has been proposed to describe changes in decision-making over the course of repeated decisions, but its mechanisms and relevance in clinical practice remain debated. While quantitative studies have reported time-related patterns in medical decisions, qualitative evidence on how DF is experienced and managed in everyday clinical settings is limited. Intensive care units (ICUs), characterised by high decision density, time pressure, and uncertainty, provide a particularly relevant context to explore these processes. This study explored intensive care physicians' views and experiences on DF and its potential impact on medical decision making in the ICU. 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 an inductive thematic analysis approach. Codes and categories were iteratively developed and grouped into higher-level themes and decision characteristics. 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) Perceived effects of DF on decision-making processes and behaviours; and (3) physicians indicate various characteristics of decisions in which the effects of DF are more likely to occur. This study provides new insights into ICU physicians' experiences of DF and presents a typology of clinical decisions according to their perceived susceptibility to DF as a hypothesis-generating framework. The findings suggest practical implications for workflow design, decision prioritisation, and team-based approaches to support clinical decision-making in the ICU.