临床医生如何与代理人讨论重症患者的偏好和价值观：一项实证分析。
How clinicians discuss critically ill patients' preferences and values with surrogates: an empirical analysis.
作者信息
Scheunemann Leslie P, Cunningham Thomas V, Arnold Robert M, Buddadhumaruk Praewpannarai, White Douglas B
机构信息
1Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA. 2Program on Ethics and Decision Making in Critical Illness, Clinical Research, Investigation and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh, Pittsburgh, PA. 3Division of Medical Humanities, University of Arkansas for Medical Sciences, Little Rock, AR. 4Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR. 5Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA. 6Palliative and Supportive Institute, University of Pittsburgh Medical Center, Pittsburgh, PA. 7Center for Bioethics and Health Law, University of Pittsburgh, Pittsburgh, PA.
出版信息
Crit Care Med. 2015 Apr;43(4):757-64. doi: 10.1097/CCM.0000000000000772.
OBJECTIVES
Although shared decision making requires clinicians to discuss the patient's values and preferences, little is known about the extent to which this occurs with surrogates in ICUs. We sought to assess whether and how clinicians talk with surrogates about incapacitated patients' preferences and values.
DESIGN
Prospective, cross-sectional study.
SETTING
Five ICUs of two hospitals.
SUBJECTS
Fifty-four physicians and 159 surrogates for 71 patients.
INTERVENTIONS
We audio-recorded 71 conferences in which clinicians and surrogates discussed life-sustaining treatment decisions for an incapacitated patient near the end of life. Two coders independently coded each instance in which clinicians or surrogates discussed the patient's previously expressed treatment preferences or values. They subcoded for values that are commonly important to patients near the end of life. They also coded treatment recommendations by clinicians that incorporated the patient's preferences or values.
MEASUREMENTS AND MAIN RESULTS
In 30% of conferences, there was no discussion about the patient's previously expressed preferences or values. In 37%, clinicians and surrogates discussed both the patient's treatment preferences and values. In the remaining 33%, clinicians and surrogates discussed either the patient's treatment preferences or values, but not both. In more than 88% of conferences, there was no conversation about the patient's values regarding autonomy and independence, emotional well-being and relationships, physical function, cognitive function, or spirituality. On average, 3.8% (SD, 4.3; range, 0-16%) of words spoken pertained to patient preferences or values.
CONCLUSIONS
In roughly a third of ICU family conferences for patients at high risk of death, neither clinicians nor surrogates discussed patients' preferences or values about end-of-life decision making. In less than 12% of conferences did participants address values of high importance to most patients, such as cognitive and physical function. Interventions are needed to ensure patients' values and preferences are elicited and integrated into end-of-life decisions in ICUs.
目的
尽管共同决策要求临床医生讨论患者的价值观和偏好，但对于在重症监护病房（ICU）中与替代决策者进行此类讨论的程度知之甚少。我们试图评估临床医生是否以及如何与替代决策者谈论无行为能力患者的偏好和价值观。
设计
前瞻性横断面研究。
地点
两家医院的五个ICU。
研究对象
71名患者的54名医生和159名替代决策者。
干预措施
我们对71次会议进行了录音，在这些会议中，临床医生和替代决策者讨论了一名临终时无行为能力患者的维持生命治疗决策。两名编码员独立对临床医生或替代决策者讨论患者先前表达的治疗偏好或价值观的每个实例进行编码。他们对临终患者通常重要的价值观进行了子编码。他们还对临床医生纳入患者偏好或价值观的治疗建议进行了编码。
测量指标和主要结果
在30%的会议中，未讨论患者先前表达的偏好或价值观。在37%的会议中，临床医生和替代决策者讨论了患者的治疗偏好和价值观。在其余33%的会议中，临床医生和替代决策者讨论了患者的治疗偏好或价值观，但并非两者都讨论。在超过88%的会议中，没有关于患者在自主性和独立性、情感幸福和人际关系、身体功能、认知功能或精神性方面价值观的讨论。平均而言，每次会议中提及患者偏好或价值观的话语占3.8%（标准差为4.3；范围为0 - 16%）。
结论
在大约三分之一针对高死亡风险患者的ICU家庭会议中，临床医生和替代决策者都未讨论患者关于临终决策的偏好或价值观。在不到12%的会议中，参与者讨论了对大多数患者非常重要的价值观，如认知和身体功能。需要采取干预措施，以确保在ICU中了解患者的价值观和偏好，并将其纳入临终决策。
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