择期手术中替代决策的准确性。

Mantravadi Anand V, Sheth Bhavna P, Gonnering Russell S, Covert Douglas J

Wills Eye Hospital, Philadelphia, Pennsylvania, USA.

J Cataract Refract Surg. 2007 Dec;33(12):2091-7. doi: 10.1016/j.jcrs.2007.07.036.

PURPOSE

To assess the accuracy of surrogate decision making for elective cataract surgery.

SETTING

Comprehensive Ophthalmology Department of Tertiary Care Hospital.

METHODS

Decisions regarding elective cataract surgery of currently competent, elderly patients were compared with the predictions of patient-identified surrogate decision makers in scenarios of current state of mental health and progressive dementia. Patients were identified (age >50 years, Mini-Mental Status Score >20, absence of significant noncataract pathology) consecutively at a scheduled clinic visit to a single provider. Preferences for cataract surgery in the current state of health and hypothetical progressive dementia were assessed on a Likert scale. The same interviewer contacted patient-identified surrogate decision makers within 48 hours. Independently, a survey of community ophthalmologists was performed. The concordance of surrogate predictions with patient preferences (32 pairs) was assessed using percentage agreement, the kappa coefficient with dichotomous Likert scale data, and chi-square analyses (concordance beyond chance).

RESULTS

In their current state of health, most patients said they would prefer to have surgery if they were deemed to have a visually significant cataract, which was accurately predicted by surrogates (72% agreement, kappa = 0.65, chi square = 16.5). In a hypothetical dementia scenario, contrary to perceptions of patients and their surrogates, proxies were unable to accurately represent a patient's wishes for elective cataract surgery (34% agreement, kappa = 0.23, chi square = 14.4). Physicians tended to withhold intervention in the dementia scenario.

CONCLUSIONS

The findings suggest that current methods of decision making in elective surgery for patients unable to make autonomous decisions may be seriously flawed. This extends previous findings of inaccuracy with the substituted judgment approach to end-of-life issues to reflect elective surgical scenarios.

目的

评估选择性白内障手术中替代决策的准确性。

地点

三级护理医院的综合眼科。

方法

将目前有行为能力的老年患者关于选择性白内障手术的决策，与患者指定的替代决策者在当前心理健康状况和进行性痴呆情况下的预测进行比较。在一次预定的门诊就诊中，连续识别出患者（年龄>50岁，简易精神状态评分>20，无明显非白内障病变），由单一医生负责。使用李克特量表评估患者在当前健康状态和假设的进行性痴呆情况下对白内障手术的偏好。同一名访谈者在48小时内联系患者指定的替代决策者。另外，对社区眼科医生进行了一项调查。使用百分比一致性、二分李克特量表数据的kappa系数以及卡方分析（一致性超出偶然）来评估替代预测与患者偏好（32对）的一致性。

结果

在当前健康状态下，大多数患者表示，如果他们被认为患有具有明显视觉影响的白内障，他们愿意接受手术，替代决策者能准确预测这一点（一致性为72%，kappa = 0.65，卡方 = 16.5）。在假设的痴呆情况下，与患者及其替代决策者的认知相反，代理人无法准确代表患者对选择性白内障手术的意愿（一致性为34%，kappa = 0.23，卡方 = 14.4）。医生在痴呆情况下倾向于不进行干预。