Norris Wendi M, Nielsen Elizabeth L, Engelberg Ruth A, Curtis J Randall
Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, University of Washington, Seattle, USA.
Chest. 2005 Jun;127(6):2180-7. doi: 10.1378/chest.127.6.2180.
Homeless people are at increased risk of critical illness and are less likely to have surrogate decision makers when critically ill. Consequently, clinicians must make decisions independently or with input from others such as ethics committees or guardians. No prior studies have examined treatment preferences of homeless to guide such decision makers.
Interviewer-administered, cross-sectional survey of homeless persons.
Homeless shelters in Seattle, WA.
Two hundred twenty-nine homeless individuals with two comparison groups: 236 physicians practicing in settings where they are likely to provide care for homeless persons and 111 patients with oxygen-dependent COPD.
Participants were asked whether they would want intubation with mechanical ventilation or cardiopulmonary resuscitation in their current health, if they were in a permanent coma, if they had severe dementia, or if they were confined to bed and dependent on others for all care.
Homeless men were more likely to want resuscitation than homeless women (p < 0.002) in coma and dementia scenarios. Homeless men and women were both more likely to want resuscitation in these scenarios than physicians (p < 0.001). Nonwhite homeless were more likely to want resuscitation than white homeless people (p < 0.033), and both were more likely to want resuscitation than physicians (p < 0.001). Homeless are also more likely to want resuscitation than patients with COPD. The majority (80%) of homeless who reported not having family or not wanting family to make medical decisions prefer a physician make decisions rather than a court-appointed guardian.
Homeless persons are more likely to prefer resuscitation than physicians and patients with severe COPD. Since physicians may be in the position of making medical decisions for homeless patients and since physicians are influenced by their own preferences when making decisions for others, physicians should be aware that, on average, homeless persons prefer more aggressive care than physicians. Hospitals serving homeless individuals should consider developing policies to address this issue.
无家可归者患重病的风险增加，且在患重病时更不太可能有替代决策者。因此，临床医生必须独立做出决策，或在伦理委员会或监护人等其他人的参与下做出决策。此前尚无研究调查无家可归者的治疗偏好以指导此类决策者。
由访谈者进行的无家可归者横断面调查。
华盛顿州西雅图的无家可归者收容所。
229名无家可归者，另有两个对照组：236名在可能为无家可归者提供护理的环境中执业的医生，以及111名患有氧依赖型慢性阻塞性肺疾病（COPD）的患者。
询问参与者，如果他们处于当前健康状态、处于永久性昏迷、患有严重痴呆症或卧床不起且所有护理都依赖他人，他们是否希望进行插管机械通气或心肺复苏。
在昏迷和痴呆情况下，无家可归的男性比无家可归的女性更希望进行复苏（p < 0.002）。在这些情况下，无家可归的男性和女性都比医生更希望进行复苏（p < 0.001）。非白人无家可归者比白人无家可归者更希望进行复苏（p < 0.033），且两者都比医生更希望进行复苏（p < 0.001）。无家可归者也比COPD患者更希望进行复苏。大多数（80%）报告没有家人或不希望家人做出医疗决策的无家可归者更喜欢由医生而不是法院指定的监护人做出决策。
无家可归者比医生和患有严重COPD的患者更倾向于进行复苏。由于医生可能处于为无家可归患者做出医疗决策的位置，且医生在为他人做决策时会受到自身偏好的影响，医生应该意识到，平均而言，无家可归者比医生更喜欢积极的治疗。为无家可归者提供服务的医院应考虑制定政策来解决这一问题。
