Apatira Latifat, Boyd Elizabeth A, Malvar Grace, Evans Leah R, Luce John M, Lo Bernard, White Douglas B
University of California, San Francisco, and San Francisco General Hospital, San Francisco, California 94143, USA.
Ann Intern Med. 2008 Dec 16;149(12):861-8. doi: 10.7326/0003-4819-149-12-200812160-00005.
Although many physicians worry that openly discussing a poor prognosis will cause patients and families to lose hope, surrogate decision makers' perspectives on this topic are largely unknown.
To determine surrogate decision makers' attitudes toward balancing hope and telling the truth when discussing prognosis.
Prospective, mixed-methods cohort study.
4 intensive care units at the University of California, San Francisco, Medical Center, San Francisco, California.
179 surrogate decision makers for incapacitated patients at high risk for death.
One-on-one, semistructured interviews with surrogates were conducted on the patients' 5th day of receiving mechanical ventilation. Constant comparative methods were used to inductively develop a framework to describe participants' responses. Validation methods included multidisciplinary analysis and member checking.
Overall, 93% (166 of 179) of surrogates felt that avoiding discussions about prognosis is an unacceptable way to maintain hope. The main explanatory theme was that timely discussion of prognosis is essential to allow family members to prepare emotionally and logistically for the possibility of a patient's death. Other themes that emerged included surrogates' belief that an accurate understanding of a patient's prognosis allows them to better support the patient and each other, a moral aversion to the idea of false hope, the perception that physicians have an obligation to discuss prognosis, and the notion that some surrogates look to physicians primarily for truth and seek hope elsewhere. A few surrogates (6 of 179) felt that physicians should withhold prognostic information because of a belief that discussing death could be emotionally damaging to the family or could negatively affect the patient's health.
The authors did not longitudinally assess whether early disclosure about prognosis predicts fewer adverse bereavement outcomes.
Most surrogates of critically ill patients do not view withholding prognostic information as an acceptable way to maintain hope, largely because timely discussions about prognosis help families begin to prepare emotionally, existentially, and practically for the possibility that a patient will die.
尽管许多医生担心公开讨论预后不良会导致患者及其家属失去希望，但关于这一话题替代决策者的观点却 largely unknown。
确定替代决策者在讨论预后时对平衡希望与告知真相的态度。
前瞻性、混合方法队列研究。
加利福尼亚州旧金山加利福尼亚大学旧金山分校医学中心的4个重症监护病房。
179名无行为能力且死亡风险高的患者的替代决策者。
在患者接受机械通气的第5天，对替代决策者进行一对一的半结构化访谈。采用持续比较法归纳得出一个框架来描述参与者的回答。验证方法包括多学科分析和成员核对。
总体而言，93%（179名中的166名）的替代决策者认为，避免讨论预后是维持希望的不可接受的方式。主要的解释主题是，及时讨论预后对于让家庭成员在情感和实际事务上为患者死亡的可能性做好准备至关重要。出现的其他主题包括替代决策者认为准确了解患者的预后能使他们更好地支持患者及彼此，对虚假希望的道德反感，认为医生有义务讨论预后，以及一些替代决策者主要期望医生告知真相并在其他地方寻求希望。少数替代决策者（179名中的6名）认为医生应隐瞒预后信息，因为他们认为讨论死亡可能会对家属造成情感伤害或对患者健康产生负面影响。
作者未纵向评估早期披露预后是否能预测较少的不良丧亲结果。
大多数重症患者的替代决策者不认为隐瞒预后信息是维持希望的可接受方式，主要是因为及时讨论预后有助于家属在情感、生存意义和实际事务上开始为患者可能死亡做好准备。
