Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA 15221, USA.
Intensive Care Med. 2012 Nov;38(11):1886-96. doi: 10.1007/s00134-012-2661-6. Epub 2012 Sep 1.
To explore norms of decision making regarding life-sustaining treatments (LSTs) at two academic medical centers (AMCs) that contribute to their opposite extremes of end-of-life ICU use.
We conducted a 4-week mixed methods case study at each AMC in 2008-2009 involving direct observation of patient care during rounds in the main medical ICU, semi-structured interviews with staff, patients, and families, and collection of artifacts (e.g., patient lists, standardized forms). We compared patterns of decision making regarding initiation, continuation, and withdrawal of LST using tests of proportions and grounded theory analysis of field note and interview transcripts.
We observed 80 patients [26 (32.5 %) ≥65 years old] staffed by 4 attendings, and interviewed 23 staff and 3 patients/families at the low-intensity AMC (LI-AMC), and observed 73 patients [26 (35.6 %) ≥65 years old] staffed by 4 attending physicians and interviewed 26 staff and 4 patients/families at the high-intensity AMC (HI-AMC). LST initiation among patients over 65 was similar, except feeding tubes (0 % LI-AMC versus 31 % HI-AMC, p = 0.002). The LI-AMC was more likely to use a time-limited trial of LST, followed by withdrawal (27 vs. 8 %, p = 0.01) and to have a known outcome of death (31 vs. 4 %, p < 0.001). We identified qualitative differences in goals of LST, the determination of "dying," concern about harms of commission versus omission, and physician self-efficacy for LST decision making.
Time-limited trials of LST at the LI-AMC and open-ended use of LST at the HI-AMC explain some of the AMCs' nationally profiled differences in end-of-life ICU use.
探索两所学术医疗中心（AMC）在维持生命治疗（LST）决策方面的规范，这两所 AMC 对生命末期 ICU 的使用有着截然相反的极端情况。
我们于 2008 年至 2009 年在每家 AMC 进行了为期 4 周的混合方法案例研究，包括在主要医疗 ICU 进行轮班时对患者护理的直接观察、对员工、患者和家属的半结构化访谈以及收集人工制品（例如，患者名单、标准化表格）。我们使用比例检验和实地记录和访谈记录的扎根理论分析比较了启动、继续和撤回 LST 的决策模式。
我们观察了由 4 名主治医生负责的 80 名患者[26 名（32.5%）≥65 岁]，并在低强度 AMC（LI-AMC）采访了 23 名员工和 3 名患者/家属，观察了由 4 名主治医生负责的 73 名患者[26 名（35.6%）≥65 岁]，并在高强度 AMC（HI-AMC）采访了 26 名员工和 4 名患者/家属。65 岁以上患者的 LST 启动情况相似，除了喂养管（0%LI-AMC 与 31%HI-AMC，p=0.002）。LI-AMC 更有可能使用有限时间的 LST 试验，然后是撤回（27%比 8%，p=0.01），并且有明确的死亡结果（31%比 4%，p<0.001）。我们确定了 LST 目标、“死亡”的确定、对委任性和避免性伤害的关注以及医生对 LST 决策的自我效能感等方面的定性差异。
LI-AMC 中 LST 的限时试验和 HI-AMC 中 LST 的开放式使用解释了一些 AMC 在生命末期 ICU 使用方面的全国性差异。
