Fratianne R B, Brandt C, Yurko L, Coffee T
Department of Surgery, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH 44109.
J Burn Care Rehabil. 1992 Sep-Oct;13(5):600-4. doi: 10.1097/00004630-199209000-00018.
Modern burn care often leads to the dilemma of what should or should not be done for patients with clinical deterioration and organ system failure who fail to respond to therapy. The questions are, "When is enough enough?" and "Who decides?" We have developed a structured conference to address these issues and to help us decide whether to recommend continued invasive diagnostic and therapeutic intervention or to allow the patient to "die with dignity." This conference can be requested by any member of the burn team who feels uncomfortable with what is being done for and/or to a patient. It is a meeting of the entire team, and its purpose is to discern the judgment of the group. When the consensus decision is to forego additional therapy, the decision is then presented to the patient (if he or she is able to understand and respond) and to the patient's family. The decision made by the group removes the responsibility of any individual from making a stressful decision if the patient's condition deteriorates abruptly. Patients who accept this decision exhibit a peaceful calm that invariably reaffirms the group dynamics. The family often experiences a great deal of relief, because they are not forced to make the decision even though they wanted it made. Inviting nurses to be active participants in the decision process builds their personal and professional self-esteem and binds the team members into a more tightly knit community. The attending staff may perceive this process as an abdication of responsibility; however, in our experience the consensus conference has led to a conviction that the wisdom of the team is always best.
对于那些临床病情恶化且器官系统功能衰竭、对治疗无反应的患者，应该做什么或不应该做什么。问题是，“什么时候才够？”以及“谁来做决定？”我们已经开展了一个结构化会议来解决这些问题，并帮助我们决定是建议继续进行侵入性诊断和治疗干预，还是让患者“尊严地死去”。烧伤治疗团队中任何对针对患者所采取的措施感到不安的成员都可以要求召开这个会议。这是整个团队的会议，其目的是洞察团队的判断。当达成的共识决定是放弃进一步治疗时，该决定随后会告知患者（如果他或她能够理解并做出回应）及其家人。如果患者病情突然恶化，团队做出的决定免除了任何个人做出压力巨大的决定的责任。接受这一决定的患者会表现出一种平静，这总是会再次确认团队的凝聚力。家属通常会感到极大的宽慰，因为即使他们希望做出决定，但他们并没有被迫去做。邀请护士积极参与决策过程能增强他们的个人和职业自尊，并使团队成员更加紧密地团结在一起。主治医护人员可能会将这个过程视为推卸责任；然而，根据我们的经验，共识会议让大家坚信团队的智慧总是最佳的。
