1Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD. 2Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins Medicine, Baltimore, MD. 3Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. 4Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD. 5Critical Care Medicine Department, National Institutes of Health, Bethesda, MD. 6Division of Pulmonary and Critical Care Medicine, University of Washington School of Medicine, Seattle, WA. 7Palliative Care Center of Excellence, University of Washington School of Medicine, Seattle, WA. 8Division of Pulmonary, Allergy and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. 9Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. 10Fostering Improvement in End-of-Life Decision Science (FIELDS) Program, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. 11Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD.
Crit Care Med. 2014 Jun;42(6):1455-62. doi: 10.1097/CCM.0000000000000227.
To evaluate the effect of 1) patient values as expressed by family members and 2) a requirement to document patients' functional prognosis on intensivists' intention to discuss withdrawal of life support in a hypothetical family meeting.
A three-armed, randomized trial.
One hundred seventy-nine U.S. hospitals with training programs in critical care accredited by the Accreditation Council for Graduate Medical Education.
Six hundred thirty intensivists recruited via e-mail invitation from a database of 1,850 eligible academic intensivists.
Each intensivist was randomized to review 10, online, clinical scenarios with a range of illness severities involving a hypothetical patient (Mrs. X). In control-group scenarios, the patient did not want continued life support without a reasonable chance of independent living. In the first experimental arm, the patient wanted life support regardless of functional outcome. In the second experimental arm, patient values were identical to the control group, but intensivists were required to record the patient's estimated 3-month functional prognosis.
Response to the question: "Would you bring up the possibility of withdrawing life support with Mrs. X's family?" answered using a five-point Likert scale. There was no effect of patient values on whether intensivists intended to discuss withdrawal of life support (p = 0.81), but intensivists randomized to record functional prognosis were 49% more likely (95% CI, 20-85%) to discuss withdrawal.
In this national, scenario-based, randomized trial, patient values had no effect on intensivists' decisions to discuss withdrawal of life support with family. However, requiring intensivists to record patients' estimated 3-month functional outcome substantially increased their intention to discuss withdrawal.
评估 1）家庭成员表达的患者价值观和 2）记录患者功能预后的要求对重症监护医师在假设的家庭会议上讨论停止生命支持的意愿的影响。
三臂随机试验。
在美国，有 179 家接受过美国住院医师规范化培训认证委员会（Accreditation Council for Graduate Medical Education）认证的重症监护培训项目的医院。
通过电子邮件邀请，从 1850 名符合条件的学术重症监护医师数据库中招募了 630 名重症监护医师。
每位重症监护医师随机查看 10 个在线临床情景，涉及各种严重程度的疾病，涉及一位假设的患者（X 女士）。在对照情景中，患者不希望在没有独立生活合理机会的情况下继续接受生命支持。在第一个实验组中，无论功能预后如何，患者都希望接受生命支持。在第二个实验组中，患者的价值观与对照组相同，但要求重症监护医师记录患者估计的 3 个月功能预后。
回答“您是否会与 X 女士的家人讨论停止生命支持的可能性？”的问题，使用 5 点李克特量表回答。患者价值观对重症监护医师是否打算讨论停止生命支持没有影响（p=0.81），但随机记录功能预后的重症监护医师讨论停止的可能性增加了 49%（95%CI，20-85%）。
在这项全国性的、基于情景的、随机试验中，患者价值观对重症监护医师与家属讨论停止生命支持的决定没有影响。然而，要求重症监护医师记录患者估计的 3 个月功能结局显著增加了他们讨论停止的意愿。
