Thomas John M, O'Leary John R, Fried Terri R
Department of Medicine, Yale University School of Medicine, 337 Crown Street, New Haven, CT, 06511, USA,
J Gen Intern Med. 2014 Jul;29(7):1048-54. doi: 10.1007/s11606-014-2830-0. Epub 2014 Mar 20.
Little is known about the differences between physicians in training and post training in their willingness to comply with patient requests at the end of life.
To compare the attitudes of attendings and residents regarding a range of patient requests at the end of life
Written, cross-sectional survey
The cohort included 191 attendings randomly selected across the state of Connecticut and 240 residents from 2 university-affiliated Internal Medicine programs.
We surveyed attendings and residents about their willingness to honor the requests of the same decisionally capable elderly patient in five scenarios involving different requests regarding end-of-life treatment.
While a large majority of both attendings and residents were willing to comply with each of the requests to withhold intubation (100 % and 94 %, respectively), to extubate (92 % and 77 %), and to give increasingly higher doses of narcotics (94 % and 71 %), a significantly larger proportion of attendings versus residents was willing to comply with each of these requests. Small proportions of attendings and residents were willing to prescribe a lethal amount of sleeping pills (3 % and 5 %, respectively) and to give a lethal injection in its current illegal state (1 % and 4 %). A significantly larger proportion of residents (32 %) compared to attendings (19 %) was willing to give a lethal injection if legal. Adjusting for sociodemographic factors, attending status was independently associated with willingness to extubate [adjusted odds ratio (AOR) = 3.0, 95 % CI = 1.6-5.7] and to give a lethal injection if legal (AOR = 0.5, 95 % CI = 0.3-0.8). The proportion of physicians willing to extubate increased across years since graduation, with the greatest differences occurring across the residency years (69 % to 86 %).
Clinical experience was an important determinant of physicians' willingness to perform multiple patient requests at the end of life, with substantial changes in attitudes occurring during residency training. More research is needed to determine whether dedicated clinical exposure for physicians in training influences attitudes.
对于处于培训阶段的医生和培训结束后的医生在临终时遵从患者请求的意愿差异，人们了解甚少。
比较主治医生和住院医生对一系列临终患者请求的态度。
书面横断面调查
该队列包括在康涅狄格州随机选取的191名主治医生以及来自两个大学附属内科项目的240名住院医生。
我们就主治医生和住院医生在五种涉及不同临终治疗请求的情景中，对同一位具备决策能力的老年患者的请求予以遵从的意愿进行了调查。
虽然绝大多数主治医生和住院医生都愿意遵从每项不进行插管的请求（分别为100%和94%）、拔管的请求（92%和77%）以及给予剂量越来越高的麻醉剂的请求（94%和71%），但与住院医生相比，愿意遵从这些请求的主治医生比例显著更高。一小部分主治医生和住院医生愿意开具致死剂量的安眠药（分别为3%和5%）以及在当前非法状态下进行致命注射（1%和4%）。如果合法化，愿意进行致命注射的住院医生比例（32%）显著高于主治医生（19%）。在对社会人口学因素进行调整后，主治医生身份与拔管意愿[调整后的优势比（AOR）=3.0，95%置信区间（CI）=1.6 - 5.7]以及如果合法化进行致命注射的意愿（AOR = 0.5，95% CI = 0.3 - 0.8）独立相关。自毕业以来，愿意拔管的医生比例逐年增加，在住院医生阶段差异最大（从69%到86%）。
临床经验是医生在临终时执行多项患者请求意愿的重要决定因素，在住院医生培训期间态度发生了重大变化。需要更多研究来确定针对处于培训阶段的医生进行专门的临床接触是否会影响态度。
