Chiong Winston, Kim Anthony S, Huang Ivy A, Farahany Nita A, Josephson S Andrew
Department of Neurology, University of California, San Francisco, San Francisco, CA.
Ann Neurol. 2014 Aug;76(2):296-304. doi: 10.1002/ana.24209. Epub 2014 Jul 9.
Some have argued that physicians should not presume to make thrombolysis decisions for incapacitated patients with acute ischemic stroke because the risks and benefits of thrombolysis involve deeply personal values. We evaluated the influence of the inability to consent and of personal health-related values on older adults' emergency treatment preferences for both ischemic stroke and cardiac arrest.
A total of 2,154 US adults age ≥50 years read vignettes in which they had either suffered an acute ischemic stroke and could be treated with thrombolysis, or had suffered a sudden cardiac arrest and could be treated with cardiopulmonary resuscitation. Participants were then asked (1) whether they would want the intervention, or (2) whether they would want to be given the intervention even if their informed consent could not be obtained. We elicited health-related values as predictors of these judgments.
Older adults were as likely to want stroke thrombolysis when unable to consent (78.1%) as when asked directly (76.2%), whereas older adults were more likely to want cardiopulmonary resuscitation when unable to consent (83.6% compared to 75.9%). Greater confidence in the medical system and reliance on statistical information in decision making were both associated with desiring thrombolysis.
Older adults regard thrombolysis no less favorably when considering a situation in which they are unable to consent. These findings provide empirical support for recent professional society recommendations to treat ischemic stroke with thrombolysis in appropriate emergency circumstances under a presumption of consent.
一些人认为，医生不应擅自为急性缺血性中风的无行为能力患者做出溶栓决策，因为溶栓的风险和益处涉及个人价值观。我们评估了无法表示同意以及个人健康相关价值观对老年人急性缺血性中风和心脏骤停紧急治疗偏好的影响。
共有2154名年龄≥50岁的美国成年人阅读了一些短文，短文中他们要么患有急性缺血性中风且可接受溶栓治疗，要么发生了心脏骤停且可接受心肺复苏。然后询问参与者：（1）他们是否希望接受干预，或者（2）即使无法获得他们的知情同意，他们是否希望接受干预。我们引出了与健康相关的价值观作为这些判断的预测因素。
老年人在无法表示同意时（78.1%）与直接询问时（76.2%）希望进行中风溶栓的可能性相同，而老年人在无法表示同意时更希望进行心肺复苏（83.6%，而直接询问时为75.9%）。对医疗系统更大的信心以及在决策中对统计信息的依赖都与希望进行溶栓有关。
老年人在考虑自己无法表示同意的情况时，对溶栓的青睐程度并不低。这些发现为近期专业协会关于在适当的紧急情况下在推定同意的前提下用溶栓治疗缺血性中风的建议提供了实证支持。
