Gutierrez Karen M
Department of Nursing and Health Sciences, Metropolitan State University, St Paul, Minnesota 55331, USA.
Crit Care Nurs Q. 2012 Oct-Dec;35(4):396-409. doi: 10.1097/CNQ.0b013e318268fe35.
This study explored the experiences of critical care nurses and physicians with advance directives (ADs) in an intensive care unit (ICU) to identify the benefits and limitations of ADs and recommendations for improvement.
METHODS, SETTING, AND SUBJECTS: This descriptive study, obtained by ethnographic means, was implemented in a 22-bed adult medical-surgical ICU in a large community hospital in the Midwestern United States. Subjects included 14 critical care nurses, 7 attending, and 3 fellow critical care physicians. Subjects were interviewed informally and formally. Patient medical records were reviewed for ADs.
Results supported numerous problems with ADs described previously and identified additional problems, including inability of ADs to prevent unwanted aggressive treatments outside of health care facilities, and patient reluctance to share ADs for fear of physicians "throwing in the towel" too early. Although most subjects described ADs as "useless," one helpful aspect was using ADs to shift perceptions of responsibility for end-of-life decision making and outcomes from the family/providers to the patient by reframing "pulling the plug" to "honoring patient wishes." Recommendations are described, including evolving the current emphasis of increasing completion of ADs to encourage patient-family discussions focused on quality of life to increase the likelihood of discussions occurring.
本研究探讨了重症监护护士和医生在重症监护病房（ICU）中使用预立医嘱（ADs）的经验，以确定预立医嘱的益处和局限性，并提出改进建议。
方法、地点和研究对象：本描述性研究采用人种志方法，在美国中西部一家大型社区医院的一个拥有22张床位的成人内科-外科ICU中进行。研究对象包括14名重症监护护士、7名主治医生和3名重症监护专科医生。对研究对象进行了非正式和正式访谈。查阅患者病历以了解预立医嘱情况。
结果证实了先前描述的预立医嘱存在的诸多问题，并发现了其他问题，包括预立医嘱无法防止在医疗机构外进行不必要的积极治疗，以及患者因担心医生过早“放弃”而不愿分享预立医嘱。尽管大多数研究对象称预立医嘱“无用”，但一个有益的方面是通过将“拔管”重新表述为“尊重患者意愿”，利用预立医嘱将临终决策和结果的责任认知从家庭/医护人员转移到患者身上。文中描述了相关建议，包括改变当前强调提高预立医嘱完成率的做法，鼓励患者与家属围绕生活质量展开讨论，以增加此类讨论发生的可能性。
