Neville Thanh H, Wiley Joshua F, Holmboe Eric S, Tseng Chi-Hong, Vespa Paul, Kleerup Eric C, Wenger Neil S
Dr. Neville is assistant professor, Department of Medicine, Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California. Mr. Wiley is a doctoral student in health and quantitative psychology, University of California, Los Angeles, Los Angeles, California. Dr. Holmboe is senior vice president, Milestones Development and Evaluation, Accreditation Council for Graduate Medical Education, and professor adjunct of medicine, Yale University School of Medicine, New Haven, Connecticut. Dr. Tseng is associate professor, Department of Medicine, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California. Dr. Vespa is professor of neurology and neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California. Dr. Kleerup is clinical professor, Department of Medicine, Division of Pulmonary and Critical Care, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California. Dr. Wenger is professor, Department of Medicine, Division of General Internal Medicine and Health Services Research, and director, Health System Ethics Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, and a scientist at RAND Health, Santa Monica, California.
Acad Med. 2015 Mar;90(3):324-30. doi: 10.1097/ACM.0000000000000617.
Knowing when patients are too ill to benefit from intensive care is essential for clinicians to recommend aggressive or palliative care as appropriate. To explore prognostic ability among critical care fellows, the authors compared fellows' and attendings' assessments of futile critical care and evaluated factors associated with assessments.
Thirty-six attendings and 14 fellows in intensive care units at the University of California, Los Angeles, were surveyed daily for three months (December 2011-March 2012) to identify patients perceived as receiving futile treatment. Frequency of futile treatment assessments and reasons listed by attendings versus fellows were compared. Predictors of futile treatment assessments by provider type were assessed using multivariate probit models.
Attendings made 6,897 assessments on 1,125 patients; fellows made 4,407 assessments on 773 patients. Fellows assessed 161 (20.8%) patients as receiving futile treatment, compared with attendings (123 [10.9%] patients, P<.001), and listed fewer reasons that treatment was futile (P<.001). Fellows were more likely to assess a patient as receiving futile treatment by the second day, whereas attendings took four days. Patients assessed as receiving futile treatment by fellows were less likely than patients so assessed by attendings to die in the hospital (51% versus 68%, P=.003) and within six months (62% versus 85%, P<.001).
Fellows made earlier assessments and judged more patients to be receiving futile treatment than attendings, and their assessments were less predictive of mortality, suggesting that assessment of treatment appropriateness develops with experience.
了解患者病情过重而无法从重症监护中获益的时间点，对于临床医生酌情推荐积极治疗或姑息治疗至关重要。为探究重症监护专科住院医生的预后判断能力，作者比较了专科住院医生和主治医生对无效重症监护的评估，并评估了与评估相关的因素。
对加利福尼亚大学洛杉矶分校重症监护病房的36名主治医生和14名专科住院医生进行了为期三个月（2011年12月至2012年3月）的每日调查，以确定被认为接受无效治疗的患者。比较了主治医生和专科住院医生对无效治疗的评估频率及列出的原因。使用多变量概率模型评估按提供者类型划分的无效治疗评估预测因素。
主治医生对1125名患者进行了6897次评估；专科住院医生对773名患者进行了4407次评估。专科住院医生评估161名（20.8%）患者接受无效治疗，而主治医生评估了123名（10.9%）患者（P<0.001），且列出的治疗无效原因较少（P<0.001）。专科住院医生在第二天更有可能评估患者接受无效治疗，而主治医生则需要四天。被专科住院医生评估为接受无效治疗的患者比被主治医生如此评估的患者在医院死亡的可能性更小（51%对68%，P=0.003），在六个月内死亡的可能性也更小（62%对85%，P<0.001）。
与主治医生相比，专科住院医生进行评估的时间更早，且判断更多患者接受无效治疗，但其评估对死亡率的预测性较低，这表明对治疗适宜性的评估是随着经验发展的。
