Prendergast Thomas J, Puntillo Kathleen A
Departments of Medicine and Anesthesiology, Dartmouth-Hitchcock Medical Center, Section of Pulmonary and Critical Care Medicine (3D), 1 Medical Center Dr, Lebanon, NH 03756, USA.
JAMA. 2002 Dec 4;288(21):2732-40. doi: 10.1001/jama.288.21.2732.
The technology and expertise of critical care practice support patients through life-threatening illnesses. Most recover; some die quickly; others, however, linger--neither improving nor acutely dying, alive but with a dwindling capacity to recover from their injury or illness. Management of these patients is often dominated by the question: Is it appropriate to continue life-sustaining therapy? Patients rarely participate in these pivotal discussions because they are either too sick or too heavily sedated. As a result, the decision often falls to the family or the surrogate decision maker, in consultation with the medical team. Decisions of such import are emotionally stressful and are often a source of disagreement. Failure to resolve such disagreements may create conflict that compromises patient care, engenders guilt among family members, and creates dissatisfaction for health care professionals. However, the potential for strained communications is mitigated if clinicians provide timely clinical and prognostic information and support the patient and family with aggressive symptom control, a comfortable setting, and continuous psychosocial support. Effective communication includes sharing the burden of decision making with family members. This shift from individual responsibility to patient-focused consensus often permits the family to understand, perhaps reluctantly and with great sadness, that intensive caring may involve letting go of life-sustaining interventions.
重症监护实践的技术和专业知识帮助患者度过危及生命的疾病。大多数患者康复；一些患者很快死亡；然而，其他患者则徘徊不前——既没有好转也没有急剧死亡，活着但从损伤或疾病中恢复的能力不断下降。对这些患者的管理往往围绕着一个问题：继续维持生命的治疗是否合适？患者很少参与这些关键讨论，因为他们要么病得太重，要么镇静过度。因此，决定往往落在家属或替代决策者身上，并与医疗团队协商。如此重要的决定在情感上压力巨大，而且往往是分歧的根源。未能解决此类分歧可能会引发冲突，损害患者护理，使家庭成员产生内疚感，并让医护人员感到不满。然而，如果临床医生及时提供临床和预后信息，并通过积极控制症状、营造舒适环境以及持续提供心理社会支持来帮助患者及其家属，那么沟通紧张的可能性就会降低。有效的沟通包括与家庭成员分担决策负担。这种从个人责任到以患者为中心的共识的转变，往往能让家属理解，也许是不情愿且带着巨大悲伤地理解，强化护理可能意味着放弃维持生命的干预措施。
