Department of Critical Care Medicine, University of Pittsburgh Medical Center, University of Pittsburgh Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA.
Crit Care Med. 2012 Aug;40(8):2281-6. doi: 10.1097/CCM.0b013e3182533317.
Although acting as a surrogate decision maker can be highly distressing for some family members of intensive care unit patients, little is known about whether there are modifiable risk factors for the occurrence of such difficulties.
To identify: 1) factors associated with lower levels of confidence among family members to function as surrogates and 2) whether the quality of clinician-family communication is associated with the timing of decisions to forego life support.
We conducted a prospective study of 230 surrogate decision makers for incapacitated, mechanically ventilated patients at high risk of death in four intensive care units at University of California San Francisco Medical Center from 2006 to 2007. Surrogates completed a questionnaire addressing their perceived ability to act as a surrogate and the quality of their communication with physicians. We used clustered multivariate logistic regression to identify predictors of low levels of perceived ability to act as a surrogate and a Cox proportional hazard model to determine whether quality of communication was associated with the timing of decisions to withdraw life support.
There was substantial variability in family members' confidence to act as surrogate decision makers, with 27% rating their perceived ability as 7 or lower on a 10-point scale. Independent predictors of lower role confidence were the lack of prior experience as a surrogate (odds ratio 2.2, 95% confidence interval [1.04-4.46], p=.04), no prior discussions with the patient about treatment preferences (odds ratio 3.7, 95% confidence interval [1.79-7.76], p<.001), and poor quality of communication with the ICU physician (odds ratio 1.2, 95% confidence interval [1.09-1.35] p<.001). Higher quality physician-family communication was associated with a significantly shorter duration of life-sustaining treatment among patients who died (β=0.11, p=.001).
Family members without prior experience as a surrogate and those who had not engaged in advanced discussions with the patient about treatment preferences were at higher risk to report less confidence in carrying out the surrogate role. Better-quality clinician-family communication was associated with both more confidence among family members to act as surrogates and a shorter duration of use of life support among patients who died.
虽然作为重症监护病房患者的替代决策人可能会让一些家属深感痛苦，但对于替代决策人是否存在可改变的风险因素知之甚少。
确定：1）与家属作为替代决策人信心较低相关的因素，2）临床医生与家属沟通的质量是否与放弃生命支持的决策时间有关。
我们对 2006 年至 2007 年在加利福尼亚大学旧金山医疗中心四个重症监护病房中，处于死亡高风险且无法自主呼吸的机械通气患者的 230 名潜在替代决策人进行了前瞻性研究。替代决策人完成了一份调查问卷，内容涉及他们作为替代决策人的感知能力以及与医生沟通的质量。我们使用聚类多变量逻辑回归来确定低水平感知能力的预测因素，并使用 Cox 比例风险模型来确定沟通质量是否与决定停止生命支持的时间有关。
家属作为替代决策人的信心存在很大差异，27%的人在 10 分制的评分中，将自己的感知能力评为 7 或更低。较低的角色信心独立预测因素包括：无先前作为替代决策人的经验（比值比 2.2，95%置信区间[1.04-4.46]，p=.04），与患者无预先讨论治疗偏好（比值比 3.7，95%置信区间[1.79-7.76]，p<.001），以及与 ICU 医生沟通质量差（比值比 1.2，95%置信区间[1.09-1.35]，p<.001）。医生与家属的沟通质量较高与死亡患者的生命支持治疗持续时间明显缩短有关（β=0.11，p=.001）。
没有先前作为替代决策人经验的家属和那些没有与患者预先讨论治疗偏好的家属更有可能报告对执行替代角色的信心较低。临床医生与家属的沟通质量较好，与家属作为替代决策人的信心较高，以及死亡患者生命支持的使用时间缩短有关。
