Netzer Giora, Sullivan Donald R
1 Division of Pulmonary and Critical Care Medicine and.
Ann Am Thorac Soc. 2014 Mar;11(3):435-41. doi: 10.1513/AnnalsATS.201309-308OT.
Most major decisions in the intensive care unit (ICU) regarding goals of care are shared by clinicians and someone other than the patient. Multicenter clinical trials focusing on improved communication between clinicians and these surrogate decision makers have not reported consistently improved outcomes. We suggest that acquired maladaptive reasoning may contribute importantly to failure of the intervention strategies tested to date. Surrogate decision makers often suffer significant psychological morbidity in the form of stress, anxiety, depression, and post-traumatic stress disorder. Family members in the ICU also suffer cognitive blunting and sleep deprivation. Their decision-making abilities are eroded by anticipatory grief and cognitive biases, while personal and family conflicts further impact their decision making. We propose recognizing a family ICU syndrome to describe the morbidity and associated decision-making impairment experienced by many family members of patients with acute critical illness (in the ICU) and chronic critical illness (in the long-term, acute care hospital). Research rigorously using models of compromised decision making may help elucidate both mechanisms of impairment and targets for intervention. Better quantifying compromised decision making and its relationship to poor outcomes will allow us to formulate and advance useful techniques. The use of decision aids and improving ICU design may provide benefit now and in the near future. In measuring interventions targeting cognitive barriers, clinically significant outcomes, such as time to decision, should be considered. Statistical approaches, such as survival models and rank statistic testing, will increase our power to detect differences in our interventions.
重症监护病房（ICU）中大多数关于治疗目标的重大决策是由临床医生和患者以外的其他人共同做出的。聚焦于改善临床医生与这些替代决策者之间沟通的多中心临床试验并未一致报告结果得到改善。我们认为，后天形成的适应不良推理可能是导致迄今为止所测试的干预策略失败的重要原因。替代决策者常常会出现以压力、焦虑、抑郁和创伤后应激障碍等形式表现的严重心理疾病。ICU中的家庭成员也会出现认知迟钝和睡眠剥夺。他们的决策能力会因预期性悲伤和认知偏差而受到损害，而个人和家庭冲突会进一步影响他们的决策。我们建议认识到一种家庭ICU综合征，以描述急性危重病（在ICU中）和慢性危重病（在长期急性护理医院中）患者的许多家庭成员所经历的疾病和相关决策障碍。使用决策受损模型进行严格研究可能有助于阐明损害机制和干预目标。更好地量化决策受损情况及其与不良结果的关系将使我们能够制定并推进有用的技术。使用决策辅助工具和改善ICU设计可能在现在和不久的将来带来益处。在衡量针对认知障碍的干预措施时，应考虑具有临床意义的结果，如决策时间。生存模型和秩统计检验等统计方法将增强我们检测干预措施差异的能力。
