Burns Jeffrey P, Mello Michelle M, Studdert David M, Puopolo Ann Louise, Truog Robert D, Brennan Troyen A
Department of Anesthesia, Harvard Medical School and Children's Hospital, Boston, MA. USA.
Crit Care Med. 2003 Aug;31(8):2107-17. doi: 10.1097/01.CCM.0000069732.65524.72.
To develop, deploy, and evaluate an intervention designed to identify and mitigate conflict in decision making in the intensive care unit.
Nonrandomized, controlled trial.
Seven intensive care units at four Boston teaching hospitals.
A total of 1,752 critically ill patients, including 873 study cases analyzed here.
Social workers interviewed families of patients deemed at high risk for decisional conflict and provided feedback to the clinical team, who then implemented measures to address the problems identified.
Patient or surrogate satisfaction with intensive care unit care and the probability of choosing a specific plan for treatment in the intensive care unit was studied. Inclusion criteria identified 873 patients at risk for decisional conflict. Thirty-nine percent of the patients in the intervention phase of the study (172 patients) received the intervention. In multivariate analyses, receiving the intervention significantly increased the likelihood of deciding to forgo resuscitation (odds ratio [OR] = 1.81, p =.017), the likelihood of choosing a treatment plan for comfort-care only (OR = 1.94, p =.018), and the likelihood of choosing an aggressive-care treatment plan (OR = 2.30, p =.002). Receiving the intervention did not significantly affect overall satisfaction with the care provided (OR = 0.68, p =.14), satisfaction with the amount of information provided (OR = 0.86, p =.44), or satisfaction with the degree of involvement in decision making (OR = 0.84, p =.54).
Although there was no impact on patient or surrogate satisfaction with care provided in the intensive care unit, the intervention did facilitate deliberative decision making in cases deemed at high risk for conflict. The lessons learned from the experience with this intervention should be helpful in ongoing efforts to improve care and to achieve outcomes desired by critically ill patients, their families, and critical care clinicians.
开发、应用并评估一项旨在识别和缓解重症监护病房决策冲突的干预措施。
非随机对照试验。
波士顿四家教学医院的七个重症监护病房。
共1752例危重症患者，其中873例为本研究分析的病例。
社会工作者对被认为存在决策冲突高风险患者的家属进行访谈，并向临床团队提供反馈，然后临床团队采取措施解决所发现的问题。
研究了患者或其代理人对重症监护病房护理的满意度以及在重症监护病房选择特定治疗方案的可能性。纳入标准确定了873例存在决策冲突风险的患者。研究干预阶段39%的患者（172例）接受了干预。在多变量分析中，接受干预显著增加了决定放弃心肺复苏的可能性（比值比[OR]=1.81，p=0.017）、仅选择舒适护理治疗方案的可能性（OR=1.94，p=0.018）以及选择积极护理治疗方案的可能性（OR=2.30，p=0.002）。接受干预对所提供护理的总体满意度（OR=0.68，p=0.14）、对所提供信息量的满意度（OR=0.86，p=0.44）或对决策参与程度的满意度（OR=0.84，p=0.54）没有显著影响。
虽然对患者或其代理人对重症监护病房所提供护理的满意度没有影响，但该干预措施确实促进了在被认为存在高冲突风险病例中的审慎决策。从该干预措施的经验中吸取的教训应有助于持续努力改善护理，并实现危重症患者及其家属以及重症监护临床医生期望的结果。
