Department of Critical Care Medicine, William Osler Health System, Brampton Civic Hospital, 2100 Bovaird Drive East, Brampton, Ontario L6R3J7, Canada.
BMC Med Ethics. 2010 Feb 10;11:1. doi: 10.1186/1472-6939-11-1.
Intensive care physicians often must rely on substitute decision makers to address all dimensions of the construct of "best interest" for incapable, critically ill patients. This task involves identifying prior wishes and to facilitate the substitute decision maker's understanding of the incapable patient's condition and their likely response to treatment. We sought to determine how well such discussions are documented in a typical intensive care unit.
Using a quality of communication instrument developed from a literature search and expert opinion, 2 investigators transcribed and analyzed 260 handwritten communications for 105 critically ill patients who died in the intensive care unit between January and June 2006. Cohen's kappa was calculated before analysis and then disagreements were resolved by consensus. We report results on a per-patient basis to represent documented communication as a process leading up to the time of death in the ICU. We report frequencies and percentages for discrete data, median (m) and interquartile range (IQR) for continuous data.
Our cohort was elderly (m 72, IQR 58-81 years) and had high APACHE II scores predictive of a high probability of death (m 28, IQR 23-36). Length of stay in the intensive care unit prior to death was short (m 2, IQR 1-5 days), and withdrawal of life support preceded death for more than half (n 57, 54%). Brain death criteria were present for 18 patients (17%). Although intensivists' communications were timely (median 17 h from admission to critical care), the person consenting on behalf of the incapable patient was explicitly documented for only 10% of patients. Life support strategies at the time of communication were noted in 45% of charts, and options for their future use were presented in 88%. Considerations relevant to determining the patient's best interest in relation to the treatment plan were not well documented. While explicit survival estimates were noted in 50% of charts, physicians infrequently documented their own predictions of the patient's functional status (20%), anticipated need for chronic care (0%), or post ICU quality of life (3%). Similarly, documentation of the patient's own perspectives on these ranged from 2-18%.
Intensivists' documentation of their communication with substitute decision makers frequently outlined the proposed plan of treatment, but often lacked evidence of discussion relevant to whether the treatment plan was expected to improve the patient's condition. Legislative standards for determination of best interest, such as the Health Care Consent Act in Ontario, Canada, may provide guidance for intensivists to optimally document the rationales for proposed treatment plans.
重症监护医师经常需要依靠替代决策人来解决无行为能力的危重病人的“最佳利益”结构的所有方面。这项任务包括确定先前的意愿，并促进替代决策人对无行为能力患者的病情及其对治疗的可能反应的理解。我们试图确定在典型的重症监护病房中，此类讨论记录的情况如何。
使用从文献检索和专家意见中开发的沟通质量工具，对 2006 年 1 月至 6 月期间在重症监护病房死亡的 105 名危重患者的 260 份手写通讯进行转录和分析。在分析前计算 Cohen 的 Kappa，然后通过共识解决分歧。我们以每位患者为基础报告结果，以代表在 ICU 死亡时间之前的记录沟通过程。我们报告离散数据的频率和百分比，连续数据的中位数（m）和四分位距（IQR）。
我们的队列年龄较大（m72，IQR58-81 岁），APACHE II 评分高，预示死亡概率高（m28，IQR23-36）。死亡前在重症监护病房的住院时间较短（m2，IQR1-5 天），超过一半（n57，54%）的患者在死亡前停止了生命支持。18 名患者（17%）出现脑死亡标准。尽管重症监护医师的沟通是及时的（中位数为入院至重症监护的 17 小时），但仅明确记录了 10%的患者代表无行为能力患者进行同意的人。在 45%的图表中记录了沟通时的生命支持策略，在 88%的图表中提出了未来使用这些策略的方案。与治疗计划相关的确定患者最佳利益的相关考虑因素记录不佳。虽然 50%的图表中都记录了明确的生存估计，但医生很少记录自己对患者功能状态的预测（20%）、预期的慢性护理需求（0%）或 ICU 后生活质量（3%）。同样，患者对这些方面的自身观点的记录范围从 2-18%。
重症监护医师与替代决策人沟通的记录经常概述了拟议的治疗计划，但往往缺乏与治疗计划是否有望改善患者病情相关的讨论证据。安大略省加拿大《医疗保健同意法》等确定最佳利益的立法标准可以为重症监护医师提供最佳指导，以优化记录拟议治疗计划的理由。
