White Douglas B, Braddock Clarence H, Bereknyei Sylvia, Curtis J Randall
Division of Pulmonary and Critical Care Medicine and Program in Medical Ethics, Department of Medicine, School of Medicine, University of California, San Francisco, CA 94143-0903, USA.
Arch Intern Med. 2007 Mar 12;167(5):461-7. doi: 10.1001/archinte.167.5.461.
In North America, families generally wish to be involved in end-of-life decisions when the patient cannot participate, yet little is known about the extent to which shared decision making occurs in intensive care units.
We audiotaped 51 physician-family conferences about major end-of-life treatment decisions at 4 hospitals from August 1, 2000, to July 31, 2002. We measured shared decision making using a previously validated instrument to assess the following 10 elements: discussing the nature of the decision, describing treatment alternatives, discussing the pros and cons of the choices, discussing uncertainty, assessing family understanding, eliciting patient values and preferences, discussing the family's role in decision making, assessing the need for input from others, exploring the context of the decision, and eliciting the family's opinion about the treatment decision. We used a mixed-effects regression model to determine predictors of shared decision making and to evaluate whether higher levels of shared decision making were associated with greater family satisfaction.
Only 2% (1/51) of decisions met all 10 criteria for shared decision making. The most frequently addressed elements were the nature of the decision (100%) and the context of the decision to be made (92%). The least frequently addressed elements were the family's role in decision making (31%) and an assessment of the family's understanding of the decision (25%). In multivariate analysis, lower family educational level was associated with less shared decision making (partial correlation coefficient, 0.34; standardized beta, .3; P = .02). Higher levels of shared decision making were associated with greater family satisfaction with communication (partial correlation coefficient, 0.15; standardized beta, .09; P = .03).
Shared decision making about end-of-life treatment choices was often incomplete, especially among less educated families. Higher levels of shared decision making were associated with greater family satisfaction. Shared decision making may be an important area for quality improvement in intensive care units.
在北美，当患者无法参与时，家属通常希望参与临终决策，但对于重症监护病房中共同决策的程度了解甚少。
我们对2000年8月1日至2002年7月31日期间4家医院的51次关于重大临终治疗决策的医患家属会议进行了录音。我们使用一种先前经过验证的工具来衡量共同决策，以评估以下10个要素：讨论决策的性质、描述治疗方案、讨论选择的利弊、讨论不确定性、评估家属的理解、引出患者的价值观和偏好、讨论家属在决策中的作用、评估是否需要他人的意见、探讨决策的背景以及引出家属对治疗决策的看法。我们使用混合效应回归模型来确定共同决策的预测因素，并评估更高水平的共同决策是否与更高的家属满意度相关。
只有2%（1/51）的决策符合共同决策的所有10条标准。最常涉及的要素是决策的性质（100%）和即将做出的决策的背景（92%）。最不常涉及的要素是家属在决策中的作用（31%）和对家属对决策理解的评估（25%）。在多变量分析中，家属教育水平较低与共同决策较少相关（偏相关系数为0.34；标准化β系数为0.3；P = 0.02）。更高水平的共同决策与家属对沟通的更高满意度相关（偏相关系数为0.15；标准化β系数为0.09；P = 0.03）。
关于临终治疗选择的共同决策往往不完整，尤其是在受教育程度较低的家庭中。更高水平的共同决策与更高的家属满意度相关。共同决策可能是重症监护病房质量改进的一个重要领域。
