维持生命治疗的偏好：患者偏好与临床医生认知之间的匹配和不匹配。
Life-sustaining treatment preferences: matches and mismatches between patients' preferences and clinicians' perceptions.
机构信息
Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, WA 98104, USA.
出版信息
J Pain Symptom Manage. 2013 Jul;46(1):9-19. doi: 10.1016/j.jpainsymman.2012.07.002. Epub 2012 Sep 24.
CONTEXT
Better clinician understanding of patients' end-of-life treatment preferences has the potential for reducing unwanted treatment, decreasing health care costs, and improving end-of-life care.
OBJECTIVES
To investigate patient preferences for life-sustaining therapies, clinicians' accuracy in understanding those preferences, and predictors of patient preference and clinician error.
METHODS
This was an observational study of 196 male veterans with chronic obstructive pulmonary disease who participated in a randomized trial. Measures included patients' preferences for mechanical ventilation (MV) and cardiopulmonary resuscitation (CPR) if needed in their current state of health, and outpatient clinicians' beliefs about those preferences.
RESULTS
Analyses were based on 54% of participants in the trial who had complete patient/clinician data on treatment preferences. Patients were more receptive to CPR than MV (76% vs. 61%; P<0.001). Preferences for both treatments were significantly associated with the importance patients assigned to avoiding life-sustaining therapies during the final week of life (MV: b=-0.11, P<0.001; CPR: b=-0.09, P=0.001). When responses were dichotomized (would/would not want treatment), clinicians' perceptions matched patient preferences in 75% of CPR cases and 61% of MV cases. Clinician errors increased as patients preferred less aggressive treatment (MV: b=-0.28, P<0.001; CPR: b=-0.32, P<0.001).
CONCLUSION
Clinicians erred more often about patients' wishes when patients did not want treatment than when they wanted it. Treatment decisions based on clinicians' perceptions could result in costly and unwanted treatments. End-of-life care could benefit from increased clinician-patient discussion about end-of-life care, particularly if discussions included patient education about risks of treatment and allowed clinicians to form and maintain accurate impressions of patients' preferences.
背景
更好地了解患者临终治疗偏好，有可能减少不必要的治疗，降低医疗保健成本，并改善临终关怀。
目的
调查患者对维持生命治疗的偏好、临床医生对这些偏好的理解准确性，以及预测患者偏好和临床医生错误的因素。
方法
这是一项对 196 名患有慢性阻塞性肺疾病的男性退伍军人进行的观察性研究，他们参加了一项随机试验。测量包括患者在当前健康状况下对机械通气（MV）和心肺复苏（CPR）的偏好，如果需要，以及门诊临床医生对这些偏好的看法。
结果
分析基于试验中 54%的有完整患者/临床医生治疗偏好数据的参与者。患者对 CPR 的接受程度高于 MV（76%对 61%；P<0.001）。对两种治疗方法的偏好均与患者在生命最后一周中对避免维持生命治疗的重要性显著相关（MV：b=-0.11，P<0.001；CPR：b=-0.09，P=0.001）。当将反应分为二分类（是否希望接受治疗）时，在 CPR 病例中，临床医生的看法与患者偏好相符的比例为 75%，在 MV 病例中为 61%。当患者倾向于接受不太积极的治疗时，临床医生的错误就会增加（MV：b=-0.28，P<0.001；CPR：b=-0.32，P<0.001）。
结论
当患者不希望接受治疗时，临床医生对患者意愿的错误判断比患者希望接受治疗时更常见。基于临床医生的看法做出的治疗决策可能导致昂贵和不必要的治疗。通过增加临床医生与患者之间关于临终关怀的讨论，特别是如果讨论包括患者关于治疗风险的教育，并允许临床医生形成和维持对患者偏好的准确印象，临终关怀可以从中受益。
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