Pattison Natalie, O'Gara Geraldine, Wigmore Timothy
Natalie Pattison is a senior clinical nursing research fellow, Geraldine O'Gara is a nurse researcher, and Timothy Wigmore is divisional medical director and consultant in critical care and anesthesia, The Royal Marsden NHS Foundation Trust, London, England.
Am J Crit Care. 2015 May;24(3):232-40. doi: 10.4037/ajcc2015715.
Little research has examined the involvement of critical care outreach teams in end-of-life decision making.
To establish how much time critical care outreach teams spend with patients who are subsequently subject to limitation of medical treatment and end-of-life decisions and how much influence the teams have on those decisions.
A single-center retrospective review, with qualitative analysis, in a large cancer center. Data from all patients referred emergently for critical care outreach from October 2010 to October 2011 who later had limitation of medical treatment or end-of-life care were retrieved. Findings were analyzed by using SPSS 19 and qualitative free-text analysis.
Of 890 patients referred for critical care outreach from October 2010 to October 2011, 377 were referred as an emergency; 108 of those had limitation of medical treatment and were included in the review. Thirty-five patients (32.4%) died while hospitalized. As a result of outreach intervention and a decision to limit medical treatment, 56 (51.9%) of the 108 patients received a formal end-of-life care plan (including care pathways, referral to palliative care team, hospice). About a fifth (21.5%) of clinical contact time is being spent on patients who subsequently are subject to limitation of medical treatment. Qualitative document analysis showed 5 emerging themes: difficulty of discussions about not attempting cardiopulmonary resuscitation, complexities in coordinating multiple teams, delays in referral and decision making, decision reversals and opaque decision making, and technical versus ethical imperatives.
A considerable amount of time is being spent on these emergency referrals, and decisions to limit medical treatment are common. The appropriateness of escalation of levels of care is often not questioned until patients become critically or acutely unwell, and outreach teams subsequently intervene.
很少有研究探讨重症监护外展团队在临终决策中的参与情况。
确定重症监护外展团队与随后接受医疗治疗限制和临终决策的患者相处的时间，以及该团队对这些决策的影响程度。
在一家大型癌症中心进行单中心回顾性研究，并进行定性分析。检索了2010年10月至2011年10月期间紧急转诊至重症监护外展的所有患者的数据，这些患者后来接受了医疗治疗限制或临终护理。使用SPSS 19和定性自由文本分析对结果进行分析。
2010年10月至2011年10月转诊至重症监护外展的890例患者中，377例为紧急转诊；其中108例接受了医疗治疗限制并纳入本研究。35例患者（32.4%）在住院期间死亡。由于外展干预和限制医疗治疗的决定，108例患者中有56例（51.9%）接受了正式的临终护理计划（包括护理路径、转诊至姑息治疗团队、临终关怀）。约五分之一（21.5%）的临床接触时间用于随后接受医疗治疗限制的患者。定性文件分析显示出5个新出现的主题：关于不尝试心肺复苏讨论的困难、多个团队协调的复杂性、转诊和决策延迟、决策逆转和不透明决策以及技术与伦理要求。
在这些紧急转诊上花费了大量时间，限制医疗治疗的决定很常见。在患者病情危急或急性不适之前，护理级别升级的适当性通常不会受到质疑，随后外展团队进行干预。
