Emergency Practice Innovation Centre, St Vincent's Hospital, 41 Victoria Pde, Fitzroy 3065, Melbourne, Victoria, Australia.
Emerg Med J. 2012 Sep;29(9):720-4. doi: 10.1136/emermed-2011-200287. Epub 2011 Oct 19.
To identify the decisions and attitudes of emergency clinicians in hypothetical scenarios involving advance directives (ADs).
An online survey distributed to members of the Australasian College for Emergency Medicine elicited decisions on commencing full treatment (CFT), limiting treatment or palliation in hypothetical clinical scenarios. Quantitative data were summarised using number and percentage.
388 surveys yielded a 13.0% response rate, including 190 fellows (51.9%) and 176 trainees (48.1%). For a 75-year-old patient with major trauma and unknown comorbidities requiring laparotomy, most participants (355/365, 97.3%) chose CFT. When an AD limiting treatment was made available, CFT decreased substantially (63/364, 17.3%), and the modal response was palliation (175/364, 48.1%). The most frequently reported influential factor in this decision was ethical obligation (82/383, 21.4%). For an elderly nursing-home resident with dementia, metastatic cancer and possible septic shock, 10.7% (39/366) chose CFT, changing little (21/365, 5.8%) with a directive requesting full treatment. The patient's presentation and history (189/375, 50.4%) overrode legal obligations (14/375, 3.7%) in influencing the decision. For a 55-year-old man with prostate cancer, hypoxia and acute respiratory distress (potentially requiring ventilatory support) saying, 'I just want to end it all,' most (233/366, 63.7%) chose CFT. A directive requesting limitation resulted in fewer decisions on CFT (43/368, 11.7%). Clear documentation was most important (100/362, 27.6%) in influencing this decision.
Hypothetical treatment decisions involving ADs made by emergency clinicians appear to be more influenced by ethical and clinical factors than by legal obligations.
确定急诊临床医生在涉及预先指示（AD）的假设情况下的决策和态度。
向澳大利亚急诊医师学院的成员分发在线调查，以确定在假设的临床情况下开始全面治疗（CFT）、限制治疗或姑息治疗的决定。使用数字和百分比总结定量数据。
388 份调查得出 13.0%的回复率，其中包括 190 名研究员（51.9%）和 176 名学员（48.1%）。对于一名 75 岁的有重大创伤且合并症不明需要剖腹术的患者，大多数参与者（365 人中的 355 人，97.3%）选择 CFT。当提供限制治疗的 AD 时，CFT 显著减少（364 人中的 63 人，17.3%），而最常见的反应是姑息治疗（364 人中的 175 人，48.1%）。在这一决策中，最常被报道的影响因素是道德义务（383 人中的 82 人，21.4%）。对于一名患有痴呆症、转移性癌症和可能的感染性休克的老年疗养院居民，10.7%（366 人中的 39 人）选择 CFT，在有要求全面治疗的指示的情况下变化很小（365 人中的 21 人，5.8%）。患者的表现和病史（375 人中的 189 人，50.4%）超过法律义务（375 人中的 14 人，3.7%），影响决策。对于一名患有前列腺癌、缺氧和急性呼吸窘迫（可能需要通气支持）的 55 岁男子，他说“我只想结束这一切”，大多数（366 人中的 233 人，63.7%）选择 CFT。要求限制的指令导致更少的 CFT 决策（368 人中的 43 人，11.7%）。明确的文件记录是影响这一决策最重要的因素（362 人中的 100 人，27.6%）。
急诊临床医生在涉及 AD 的假设治疗决策中，似乎更多地受到伦理和临床因素的影响，而不是法律义务的影响。
