Royal North Shore Hospital, Sydney, NSW, Australia.
Crit Care Resusc. 2012 Mar;14(1):81-7.
Assessing the appropriateness of continuing life support is a difficult task for intensive care unit staff. Part of this difficulty relates to prognostic uncertainty and the varying reliability of clinical decisions. Uncertainty about prognosis is quickly recognised by patients and families, and can be a source of mistrust and potential conflict. We discuss the reasons for uncertainty and outline key measures to reduce and manage such uncertainty. Practical certainty, where the clinicians are as certain as they can be, with both prognostication and knowledge of patient wishes, may be an appropriate concept for physicians engaged in end-of-life decisions. It involves accurate prognostication, informed surrogates, advance care planning, time to assess response, and the collective wisdom of experienced clinicians. The family conference should develop an agreed plan through shared decision making. The collective wisdom of experienced health care workers with good communication skills and informed patient advocates increases the likelihood of achieving practical certainty and the best decisions. However, greater time and effort seems to be required to improve end-of-life care in the ICU.
评估是否继续进行生命支持是重症监护病房工作人员的一项艰巨任务。部分困难与预后不确定性和临床决策的可靠性差异有关。患者和家属很快就会意识到预后的不确定性，这可能是不信任和潜在冲突的根源。我们讨论了不确定性的原因，并概述了减少和管理这种不确定性的关键措施。在生命末期决策中，对于医生来说，实际确定是一个合适的概念，即在预后和了解患者意愿方面尽可能确定。它涉及准确的预后判断、知情的代理人、预先护理计划、评估反应的时间以及经验丰富的临床医生的集体智慧。家庭会议应通过共同决策制定商定的计划。具有良好沟通技巧和知情患者代言人的经验丰富的医疗保健工作者的集体智慧增加了实现实际确定和最佳决策的可能性。然而，似乎需要更多的时间和精力来改善重症监护病房的临终关怀。
