Einstein David J, Einstein Katherine Levine, Mathew Paul
1Division of Hematology/Oncology, Tufts Medical Center, Boston, Massachusetts.
3Department of Political Science, Boston University, Boston, Massachusetts.
J Palliat Med. 2015 Jun;18(6):535-41. doi: 10.1089/jpm.2014.0373.
Patients with treatment-resistant advanced cancer rarely benefit from cardiopulmonary resuscitation (CPR) but infrequently discuss end-of-life care with physicians until hospitalized. Admitting resident physicians may conduct initial code status discussions, but may elicit patients' preferences without providing necessary guidance.
We surveyed residents' approach to code status discussions to identify barriers hindering informed decision making.
We developed an online case-based survey and enrolled subjects via e-mail requests to program directors. U.S. internal medicine residents (n=358; response rate 22.0%) from 19 programs participated. We measured respondents' likelihood of discussing prognosis and benefit of CPR, likelihood of offering code status recommendations, preference for discussing code status independent of attending physicians, and satisfaction with end-of-life discussions.
Nearly all residents felt CPR would be unhelpful. Yet fewer than half (46.7%) were likely to discuss an estimate of prognosis and the value of CPR with the patient. Only 30% were likely to offer a recommendation on CPR. A majority (69%) of residents who were unwilling to offer a recommendation stated that deference to patient autonomy prevented them from providing guidance. Residents preferred to discuss code status independent of attendings, primarily due to a sense of responsibility. Ultimately, only a minority was satisfied with end-of-life discussions.
U.S. internal medicine resident physicians are unlikely to discuss prognosis or offer recommendations on CPR in treatment-refractory cancer principally because of a conflict with their concept of patient autonomy. Given the futility associated with CPR in this setting, these data define an unmet need in training and practice.
难治性晚期癌症患者很少能从心肺复苏（CPR）中获益，但在住院前很少与医生讨论临终关怀问题。住院医师可能会进行初步的抢救状态讨论，但可能在未提供必要指导的情况下引出患者的偏好。
我们调查了住院医师进行抢救状态讨论的方式，以确定阻碍知情决策的障碍。
我们开发了一项基于案例的在线调查，并通过电子邮件向项目主任发送请求来招募受试者。来自19个项目的美国内科住院医师（n = 358；回复率22.0%）参与了调查。我们测量了受访者讨论心肺复苏预后和益处的可能性、提供抢救状态建议的可能性、独立于主治医生讨论抢救状态的偏好以及对临终讨论的满意度。
几乎所有住院医师都认为心肺复苏没有帮助。然而，不到一半（46.7%）的人可能会与患者讨论预后估计和心肺复苏的价值。只有30%的人可能会就心肺复苏提出建议。大多数（69%）不愿意提出建议的住院医师表示，尊重患者自主权使他们无法提供指导。住院医师更愿意独立于主治医生讨论抢救状态，主要是出于责任感。最终，只有少数人对临终讨论感到满意。
美国内科住院医师不太可能在难治性癌症中讨论预后或就心肺复苏提出建议，主要是因为这与他们对患者自主权的观念相冲突。鉴于在这种情况下心肺复苏的无效性，这些数据表明在培训和实践中存在未满足的需求。
