护士与医生在重症监护患者是否接受无效治疗问题上的一致性。

Concordance of Nurses and Physicians on Whether Critical Care Patients are Receiving Futile Treatment.

作者信息

Neville Thanh H, Wiley Joshua F, Yamamoto Myrtle C, Flitcraft Mark, Anderson Barbara, Curtis J Randall, Wenger Neil S

机构信息

Thanh H. Neville is an assistant clinical professor, Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine, University of California Los Angeles (UCLA). Joshua F. Wiley is a doctoral student in the Department of Psychology, UCLA and a senior analyst for the Elkhart Group Ltd, Columbia City, Indiana. Myrtle C. Yamamoto is a manager in quality improvement, Department of Medicine, David Geffen School of Medicine, UCLA. Mark Flitcraft is the nursing director of the medical intensive care unit, Department of Nursing, David Geffen School of Medicine, UCLA. Barbara Anderson is nursing director of the neuroscience critical care unit, Department of Nursing, David Geffin School of Medicine, UCLA. J. Randall Curtis is a professor, Division of Pulmonary and Critical Care, University of Washington, Seattle. Neil S. Wenger is a professor, UCLA Health Ethics Center, Department of Medicine, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, UCLA and a researcher at RAND Health, Santa Monica, California.

出版信息

Am J Crit Care. 2015 Sep;24(5):403-10. doi: 10.4037/ajcc2015476.

DOI:10.4037/ajcc2015476

PMID:26330433

Abstract

BACKGROUND

Nurses and physicians often describe critical care that is not expected to provide meaningful benefit to a patient as futile, and providing treatments perceived as futile is associated with moral distress.

OBJECTIVE

To explore concordance of physicians' and nurses' assessments of futile critical care.

METHODS

A focus group of clinicians developed a consensus definition of "futile" critical care. Daily for 3 months, critical care physicians and nurses in a health care system identified patients perceived to be receiving futile treatment. Assessments and patients' survival were compared between nurses and physicians.

RESULTS

Nurses and physicians made 6254 shared assessments on 1086 patients. Nurses and physicians assessed approximately the same number of patients as receiving futile treatment (110 for nurses vs 113 for physicians, P = .82); however, concordance was low as to which patients were assessed as receiving futile treatment (κ = 0.46). The 110 patients categorized by nurses as receiving futile treatment had lower 6-month mortality than did the 113 patients so assessed by physicians (68% vs 85%, P = .005). Patients who were assessed as receiving futile treatment by both providers were more likely to die in the hospital than were patients assessed as receiving futile treatment by the nurse alone (76% vs 32%, P < .001) or by the physician alone (76% vs 57%, P = .04).

CONCLUSIONS

Interprofessional concordance on provision of critical care perceived to be futile is low; however, joint predictions between physicians and nurses were most predictive of patients' outcomes, suggesting value in collaborative decision making.

摘要

背景

护士和医生常将预期不会给患者带来显著益处的重症监护描述为无效治疗，而提供被视为无效的治疗会引发道德困扰。

目的

探讨医生和护士对无效重症监护评估的一致性。

方法

一个临床医生焦点小组制定了“无效”重症监护的共识定义。在3个月的时间里，医疗系统中的重症监护医生和护士每天识别被认为正在接受无效治疗的患者。比较护士和医生的评估结果以及患者的生存情况。

结果

护士和医生对1086名患者进行了6254次共同评估。护士和医生评估为接受无效治疗的患者数量大致相同（护士为110例，医生为113例，P = 0.82）；然而，在哪些患者被评估为接受无效治疗方面，一致性较低（κ = 0.46）。护士归类为接受无效治疗的110名患者6个月死亡率低于医生评估的113名患者（68%对85%，P = 0.005）。被双方评估为接受无效治疗的患者比仅被护士评估为接受无效治疗的患者（76%对32%，P < 0.001）或仅被医生评估为接受无效治疗的患者（76%对57%，P = 0.04）更有可能在医院死亡。