Center for Communication and Disparities Research, Department of Family Medicine, and Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
Patient Educ Couns. 2021 Nov;104(11):2635-2642. doi: 10.1016/j.pec.2021.07.030. Epub 2021 Jul 17.
Epistemic uncertainty refers to situations in which available evidence is insufficient or unreliable, often accompanied by complexity due to novel contexts, multifactorial causation, and emerging options (the "unknowable unknown"). It stands in contrast to aleatory uncertainty where probabilities are known, and potential benefits and harms can be calculated and presented graphically (the "knowable unknown").
Epistemic uncertainty is common, and encompasses uncertainty about the nature of the illness, whom to entrust with one's care, and one's ability to adapt and cope. Communication about the "unknowable unknown" occurs infrequently and ineffectively, and there is little research on improving communication in the face of epistemic and complex uncertainty. Terror Management Theory (TMT) predicts that in encountering serious illness, people engage in "worldview defense" - suppressing death-related thoughts, affiliating with like-minded others, and developing cognitive rigidity and intolerance of information that challenges their worldview. Mindfulness is associated with diminished defensive worldview reactions and cognitive rigidity, and greater tolerance of ambiguity. Shared mind encompasses shared understanding and affective attunement.
For clinicians and seriously ill patients facing epistemic uncertainty, psychologically-informed interventions that promote mindfulness and shared mind offer promise in promoting open discussions regarding prognostic uncertainty, advance care planning, and treatment decision-making.
认知不确定性是指证据不足或不可靠的情况，通常伴随着新颖的背景、多因素因果关系和新兴选择所带来的复杂性（“未知的未知”）。它与机遇不确定性形成对比，在机遇不确定性中，概率是已知的，并且可以计算和以图形方式呈现潜在的收益和危害（“已知的未知”）。
认知不确定性很常见，包括对疾病性质、将护理托付给谁以及适应和应对能力的不确定性。关于“未知的未知”的沟通很少且效果不佳，而且在面对认知和复杂不确定性时，改善沟通的研究甚少。恐怖管理理论（TMT）预测，在遇到严重疾病时，人们会进行“世界观防御”——抑制与死亡相关的想法，与志同道合的人结盟，并发展出认知僵化和不容忍挑战他们世界观的信息的能力。正念与减少防御性世界观反应和认知僵化以及对模糊性的更大容忍度有关。共享思维包括共同的理解和情感协调。
对于面临认知不确定性的临床医生和重病患者，以心理学为基础的干预措施，如促进正念和共享思维，有望促进关于预后不确定性、预先护理计划和治疗决策的开放讨论。
