Albert Einstein Medical Center, Philadelphia, PA, USA.
Pediatr Crit Care Med. 2012 Sep;13(5):e311-5. doi: 10.1097/PCC.0b013e31824ea12c.
Many hospitals have established medical futility policies allowing a physician to withdraw or withhold treatment considered futile against families' wishes, although little is known on how these policies are used. The goal of our study was to elucidate the perspective of pediatric critical care physicians on futility.
We sent an anonymous survey to all active members of the American Academy of Pediatrics Section of Critical Care, using Survey Monkey http://www.surveymonkey.com as the questionnaire tool. The survey included four clinical vignettes where families desired care that could be perceived as futile care. In each scenario, participants were asked if they would go against the families' wishes and how they would resolve the conflict.
There were 266 of 618 (43%) respondents. For an infant with severe hypoxic ischemic injury and intestinal failure, the majority of physicians (83.7%) would not enact a unilateral do not attempt resuscitation order. For an oncology patient with multiorgan system failure and encephalopathy, the majority (90.4%) would not enact a unilateral donotattemptresuscitation. In the case where a child was declared brain dead, 54.3% of physicians would support unilateral donotattemptresuscitation, yet a third (33.1%) would continue mechanical ventilation. In the case of cardiac surgery for a patient with trisomy 13, the majority (67.1%) would not advocate for surgery. In most scenarios, intensivists cited consultation from the ethics committee (53.8%-76.6%) as the most appropriate way to resolve the conflict. Qualitative data revealed intensivists would prefer to honor families' wishes and utilize time with support from a multidisciplinary team rather than unilateral do not attempt resuscitation to resolve these conflicts.
The majority of pediatric intensivists are not in support of unilateral do-not-attempt resuscitation or withholding care against families' wishes for a variety of reasons. Given this understandable reluctance on the part of the physicians for enforcing decisions, providing unqualified support to families at this difficult time is imperative. Further research is needed to facilitate decision making that respects the moral integrity of families and physicians.
许多医院都制定了医疗无效政策，允许医生根据家属的意愿撤回或停止被认为无效的治疗，但对于这些政策的实际应用情况却知之甚少。本研究旨在阐明儿科重症监护医师对无效医疗的看法。
我们使用 Survey Monkey（www.surveymonkey.com）向美国儿科学会危重病分会的所有活跃成员发送了一份匿名调查，调查包括四个临床病例，患者家属希望进行可能被视为无效的治疗。在每种情况下，参与者都被问到他们是否会违背家属的意愿，以及他们将如何解决冲突。
共有 618 名医师中的 266 名（43%）作出回应。对于一名患有严重缺氧缺血性损伤和肠衰竭的婴儿，大多数医生（83.7%）不会单方面下达不复苏医嘱。对于一名患有多器官系统衰竭和脑病的肿瘤患者，大多数医生（90.4%）不会单方面下达不复苏医嘱。在患儿被宣布脑死亡的情况下，54.3%的医生会支持单方面不复苏，但有三分之一（33.1%）的医生会继续进行机械通气。在患有 13 三体综合征的患者进行心脏手术的情况下，大多数医生（67.1%）不会主张进行手术。在大多数情况下，重症监护医师认为咨询伦理委员会（53.8%-76.6%）是解决冲突最恰当的方法。定性数据分析显示，重症监护医师更愿意尊重家属的意愿，并在多学科团队的支持下使用时间，而不是单方面不复苏来解决这些冲突。
大多数儿科重症监护医师出于多种原因不支持单方面不复苏或停止治疗，违背家属的意愿。鉴于医生在执行这些决策时的这种可以理解的不情愿，在这个困难时期，无条件地支持家属是至关重要的。需要进一步的研究来促进决策制定，以尊重家庭和医生的道德完整性。
