Fourfold Pattern & End of Life Decisions


This is the Fourfold Pattern of Prospect Theory from Thinking, Fast and Slow.


Fourfold Pattern
Table courtesy of Innovation Garden.

Broyhill Asset Management explains what each quadrant represents.

  • In the top left cell, people are willing to accept less than the expected value of a gamble to lock in a sure thing. We all know “something” is better than “nothing.”
  • The possibility effect in the bottom left cell explains why lotteries are popular. Dangle a big enough Powerball number in front of people and ticket buyers will line up, almost indifferent to their odds of winning. A ticket comes with the right to dream.The bottom right cell is where insurance is bought. People are willing to pay much more than expected value for an insurance policy, to eliminate anxiety and purchase peace of mind.
  • The bottom right cell is where insurance is bought. People are willing to pay much more than expected value for an insurance policy, to eliminate anxiety and purchase peace of mind.
  • Many difficult situations develop in the top right cell, where people faced with bad options make reckless wagers. Risk taking in this instance can turn a manageable failure into a complete disaster, simply because the thought of taking a large loss is too painful to make the rational decision that it is time to move on. Instead, this is where many companies in structurally challenging industries burn precious assets in wasted attempts to catch up.

What I learned from reading Being Mortal is people with terminal illnesses and making end-of-life decisions are operating in the upper right quadrant. But they tend to think they are operating in the lower left quadrant.

They want to try every aggressive treatment or unapproved drug because of the possibility of a cure.  Like all of us, they will overweight the odds. They may be thinking a 1% chance is really a 5 or 10% chance.

Or they may be overestimating how much more life these aggressive treatments may add. It may be only a few months to a year while the patient thinks it may add 5 or more.

By making decisions in the lower left quadrant they are ignoring the effect these aggressive treatments may have on their quality of life. If it extends your life by a year but if it is painful and you can’t continue doing what you love, is it worth it?

There is a reason many Doctors themselves don’t pursue aggressive treatments when faced with terminal illnesses. They know the odds. They know the effects. They focus on their quality of life over the quantity.

Being Mortal is in part a guide for Doctors to redirect patients’ decision-making from the lower-left quadrant to the upper-right quadrant. With a terminal illness, it is a series of tough decisions. Doctor, patient, and the patient’s family need to have open and honest dialogs about their options and decide on the least worst option. The option that doesn’t cause undue suffering, allows the patient to do what they love to do as much as possible,  and – most importantly – it allows the patient to remain in control of their life’s story all the way to the end.

Referenced Books:

Thinking, Fast and Slow by Daniel Kahneman

Being Mortal by Dr. Atul Gawande



Being Mortal

One day we will die.

I’m not trying to be profound. It is a fact of life. Barring an untimely accident, we will also grow old before then. For two events that we know for sure are going to happen, we are extremely ill-prepared for them.

Dr. Atul Gawande’s book Being Mortal is trying to change that. Confronting old age and our mortality is a series of hard questions and choices. Preparing ourselves and discussing these hard choices with our loved ones before they occur alleviates some of the burden and stress when these decisions need to be made. Discussing the hard stuff now makes sure that what you want is implemented. If the hard decision is left to your loved ones to make at the time of an event then they will make a decision from their perspective and under duress.

Being Mortal is not just about the end of life. The book is a great starting point when thinking about elder care. The struggle families have when the role of parent and child are reversed. The good and the bad of nursing homes. And how to allow the elderly to remain in control of their lives.

We will all face these issues as a child and as someone who will get old too. It is an important book to read.

Being Mortal by Dr. Atul Gawande

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