Pearlman R A, Cain K C, Starks H, Cole W G, Uhlmann R F, Patrick D L
Geriatric Research, Education and Clinical Center, Veterans Affairs Puget Sound Health Care System, Seattle, Washington 98108, USA.
J Palliat Med. 2000 Spring;3(1):37-48. doi: 10.1089/jpm.2000.3.37.
Surrogates and clinicians often make treatment decisions for decisionally incapacitated patients with limited knowledge of their preferences. This study examined patients' life-sustaining treatment preferences to facilitate advance care planning discussions and surrogate decision making.
We interviewed 342 participants from 7 groups: younger and older well adults; persons with chronic illness, terminal cancer, and acquired immunodeficiency syndrome (AIDS); stroke survivors; and nursing home residents. Preferences for antibiotics, short- and long-term mechanical ventilation, hemodialysis, tube feeding, and cardiopulmonary resuscitation (CPR) were elicited for each participant's current health state and three hypothetical health states representing severe dementia, coma, and severe stroke.
Participants chose to forego more invasive or long-term treatments at a higher rate than less invasive, short-term treatments in all health states. Participants were much more willing to forego treatments in coma than in their current health state, with stroke and dementia somewhere in between. Participants who were older, female, had worse functional status, had more depressive symptoms, or lived in a nursing home were more inclined to forego treatment in their current health state. In contrast, treatment preferences in hypothetical health states showed either no associations or much weaker associations with these factors. Participants who were willing to accept more invasive treatments were highly likely to accept less invasive treatments and participants who preferred to forego a less invasive treatment were highly likely to forego more invasive treatments. Participants who preferred to receive a treatment in a health state with severe impairments were highly likely to want the same treatment in a less impaired health state. Similarly, participants who preferred to forego a treatment in a less impaired health state were highly likely to forego the same treatment in a more impaired state.
In advance care planning discussions, clinicians might explore with patients their preferences about short- and long-term treatments with variability in their invasiveness (including CPR) in both their current health state and hypothetical situations representing different levels of functional impairment. When surrogates have no knowledge about the wishes of formerly competent patients, clinicians may help them with medical decisions by discussing what other people commonly want in similar circumstances.
代理人和临床医生在为缺乏决策能力的患者做出治疗决策时，往往对患者的偏好了解有限。本研究调查了患者对维持生命治疗的偏好，以促进预先护理计划的讨论和代理人决策。
我们采访了来自7个组的342名参与者：年轻和年长的健康成年人；慢性病患者、晚期癌症患者和获得性免疫缺陷综合征（艾滋病）患者；中风幸存者；以及养老院居民。针对每位参与者当前的健康状况以及代表严重痴呆、昏迷和严重中风的三种假设健康状况，询问了他们对抗生素、短期和长期机械通气、血液透析、管饲和心肺复苏（CPR）的偏好。
在所有健康状况下，参与者选择放弃侵入性更强或长期治疗的比例高于侵入性较小、短期治疗的比例。与当前健康状况相比，参与者更愿意在昏迷状态下放弃治疗，中风和痴呆状态下的意愿则介于两者之间。年龄较大、女性、功能状态较差、抑郁症状较多或住在养老院的参与者，更倾向于在当前健康状况下放弃治疗。相比之下，在假设健康状况下的治疗偏好与这些因素要么没有关联，要么关联较弱。愿意接受侵入性更强治疗的参与者很可能也会接受侵入性较小的治疗，而倾向于放弃侵入性较小治疗的参与者很可能也会放弃侵入性更强的治疗。在严重受损健康状况下倾向于接受某种治疗的参与者，在受损较轻的健康状况下很可能也想要同样的治疗。同样，在受损较轻健康状况下倾向于放弃某种治疗的参与者，在受损更严重的状态下很可能也会放弃同样的治疗。
在预先护理计划的讨论中，临床医生可以与患者探讨他们在当前健康状况以及代表不同功能损害程度的假设情况下，对侵入性不同（包括心肺复苏）的短期和长期治疗的偏好。当代理人不了解先前有行为能力患者的意愿时，临床医生可以通过讨论其他人在类似情况下通常的意愿，帮助他们做出医疗决策。
