Holloway Robert G, Benesch Curtis G, Burgin W Scott, Zentner Justine B
Department of Neurology, University of Rochester School of Medicine, Rochester, NY 14642, USA.
JAMA. 2005 Aug 10;294(6):725-33. doi: 10.1001/jama.294.6.725.
An increasing number of deaths following severe stroke are due to terminal extubations. Variation in withdrawal-of-care practices suggests the possibility of unnecessary prolongation of suffering or of unwanted deaths.
To review the available evidence on prognosis in mechanically ventilated stroke patients and to provide an overall framework to optimize decision making for clinicians, patients, and families.
Search of MEDLINE from 1980 through March 2005 for English-language articles addressing prognosis in mechanically ventilated stroke patients. From 689 articles identified, we selected 17 for further review. We also identified factors that influence, and decision-making biases that may result, in overuse or underuse of life-sustaining therapies, with a particular emphasis on mechanical ventilation.
Overall mortality among mechanically ventilated stroke patients is high, with a 30-day death rate approximating 58% (range in literature, 46%-75%). Although data are limited, among survivors as many as one third may have no or only slight disability, yet many others have severe disability. One can further refine prognosis according to knowledge of stroke syndromes, early patient characteristics, use of clinical prediction rules, and the need for continuing interventions. Factors influencing preferences for life-sustaining treatments include the severity and pattern of future clinical deficits, the probability of these deficits, and the burdens of treatments. Decision-making biases that may affect withdrawal-of-treatment decisions include erroneous prognostic estimates, inappropriate methods of communicating evidence, misunderstanding patient values and expectations, and failing to appreciate the extent to which patients can physically and psychologically adapt.
Although prognosis among mechanically ventilated stroke patients is generally poor, a minority do survive without severe disability. Prognosis can be assessed according to clinical presentation and patient characteristics. There is an urgent need to better understand the marked variation in the care of these patients and to reliably measure and improve the patient-centeredness of such decisions.
严重中风后死亡人数的增加是由于终末期拔管所致。撤机护理实践的差异表明存在不必要地延长痛苦或意外死亡的可能性。
回顾机械通气中风患者预后的现有证据，并为临床医生、患者及其家属提供一个优化决策的总体框架。
检索1980年至2005年3月的MEDLINE数据库，查找关于机械通气中风患者预后的英文文章。从检索到的689篇文章中，我们选择了17篇进行进一步综述。我们还确定了影响维持生命治疗过度使用或使用不足的因素以及可能导致的决策偏差，特别关注机械通气。
机械通气中风患者的总体死亡率很高，30天死亡率约为58%（文献报道范围为46%-75%）。尽管数据有限，但在幸存者中，多达三分之一可能没有残疾或只有轻微残疾，然而其他许多人有严重残疾。根据中风综合征的知识、患者早期特征、临床预测规则的使用以及持续干预的需求，可以进一步细化预后。影响维持生命治疗偏好的因素包括未来临床缺陷的严重程度和模式、这些缺陷的可能性以及治疗负担。可能影响撤机决策的决策偏差包括错误的预后估计、传达证据的不当方法、对患者价值观和期望的误解以及未能认识到患者在身体和心理上能够适应的程度。
虽然机械通气中风患者的预后通常较差，但少数患者确实存活且没有严重残疾。可以根据临床表现和患者特征评估预后。迫切需要更好地理解这些患者护理方面的显著差异，并可靠地衡量和提高此类决策的以患者为中心程度。
