Zib Martina, Saul Peter
Department of Anaesthesia and Intensive Care, John Hunter Hospital, Newcastle, NSW, Australia.
Crit Care Resusc. 2007 Jun;9(2):213-8.
Withdrawal of potentially life-prolonging treatments is a common procedure in most intensive care units. Until recently, quality improvement activities have been hampered by the absence of a clear sense of "best practice" in this complex area.
This pilot audit addresses the feasibility of developing an end-of-life (EOL) decision-making audit and quality improvement tool and applying it in the intensive care setting.
Between November 2005 and April 2006, treatment was withdrawn from 47 patients in our ICU. Their charts were audited, and a structured interview was conducted with the intensivist who documented the decision. We defined treatment withdrawal as the cessation of mechanical ventilation and all other forms of life support in the anticipation of the patient's death.
55% of ICU deaths were the result of treatment withdrawal. Overwhelmingly, treatment failure or futility was the reason cited for withdrawal. There were no cases of conflict between the medical team and the patient's family. The level of confidence among intensivists about EOL decision-making was high. Consultation with ICU colleagues was rated as the most helpful factor in decisionmaking. Intensivists wished for earlier and more active support from the admitting medical officers in decisionmaking. Strong support for advance planning and for audit of EOL decision-making was highlighted.
A current ICU quality improvement review lists EOL management as a possible audit item (Curtis et al. Crit Care Med 2006; 34: 211). Our study demonstrated the feasibility of developing a quality improvement tool for EOL decision-making and applying it in the intensive care setting. As evidence about the process of EOL decisionmaking accumulates, that process should become a component of quality assurance audit in intensive care.
在大多数重症监护病房，撤除可能延长生命的治疗是一种常见的操作。直到最近，由于在这个复杂领域缺乏明确的“最佳实践”意识，质量改进活动受到了阻碍。
这项试点审核探讨了开发临终（EOL）决策审核和质量改进工具并将其应用于重症监护环境的可行性。
2005年11月至2006年4月期间，我们重症监护病房的47例患者接受了治疗撤除。对他们的病历进行了审核，并与记录该决策的重症监护医生进行了结构化访谈。我们将治疗撤除定义为在预期患者死亡时停止机械通气和所有其他形式的生命支持。
55%的重症监护病房死亡是治疗撤除的结果。绝大多数情况下，治疗失败或无效是撤除治疗的原因。没有医疗团队与患者家属之间发生冲突的案例。重症监护医生对临终决策的信心水平很高。与重症监护病房同事的会诊被评为决策中最有帮助的因素。重症监护医生希望在决策过程中能更早、更积极地得到收治医生的支持。强调了对预先规划和临终决策审核的大力支持。
当前的重症监护病房质量改进评估将临终管理列为可能的审核项目（Curtis等人，《重症医学》2006年；34：211）。我们的研究证明了开发临终决策质量改进工具并将其应用于重症监护环境的可行性。随着关于临终决策过程的证据不断积累，该过程应成为重症监护质量保证审核的一个组成部分。
