Leder Nadja, Schwarzkopf Daniel, Reinhart Konrad, Witte Otto W, Pfeifer Rüüdiger, Hartog Christiane S
Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Center for Sepsis Control and Care (CSCC), Jena University Hospital, Department of Neurology, Jena University Hospital, Department of Internal Medicine I, Jena University Hospital.
Dtsch Arztebl Int. 2015 Oct 23;112(43):723-9. doi: 10.3238/arztebl.2015.0723.
Nearly every fourth person in Germany has an advance directive that is to be used in certain medical situations. It is questionable, however, whether advance directives truly influence important treatment decisions in the intensive care unit. We studied the extent to which doctors and patients' relatives agree on the applicability of advance directives in the acute setting.
A prospective study was carried out by questionnaire among the physicians and relatives of 50 patients with advance directives who were hospitalized on four different multidisciplinary intensive care units. The answers of 25 residents in training, 14 senior physicians, and 19 relatives were analyzed both quantitatively and qualitatively. The extent of agreement was assessed by means of Gwet's AC1 with linear weighting.
In most of the advance directives, the conditions under which they were meant to apply were stated in broad, general terms in prewritten blocks of text. 23 of the 50 patients (46%) died. All relatives stated that they were very familiar with the patients' wishes; 18 of 19 were legally responsible for decision-making. In assessing whether the advance directive was applicable to the situation at hand, the strength of agreement between physicians and relatives as well as between the two groups of physicians was only fair and non-significant (0.35; 95% confidence interval [CI]: -0.01 to 0.71; p = 0.059 and 0.24; 95% CI: -0.03 to 0.50; p = 0.079). The relatives found the advance directives more useful than the doctors did (median, 5 vs. 3 [p = 0.018] on a Likert scale ranging from 0 [not useful at all] to 5 [very useful]) and favored their literal application (median, 5 vs. 4 [p = 0.018] on a Likert scale ranging from 0 [favoring the doctor's interpretation] to 5 [favoring literal application]). 30 days after the decision, 13 relatives (68%) felt that the patient's wishes had been fully complied with.
These groups' clearly differing assessments of the applicability of advance directives imply that the currently most common types of advance directive are not suitable for use in intensive care. In order to support patients' relatives in their role as surrogate participants in decision-making, improved advance directives should be developed, and their implementation should be incorporated into the training and continuing medical education of intensive-care physicians.
在德国，近四分之一的人有一份预先指示，以备在某些医疗情况下使用。然而，预先指示是否真的会影响重症监护病房中的重要治疗决策，这是值得怀疑的。我们研究了医生和患者亲属在急性情况下对预先指示适用性的认同程度。
通过问卷调查对50名有预先指示且在四个不同多学科重症监护病房住院的患者的医生和亲属进行了一项前瞻性研究。对25名住院医师、14名高级医师和19名亲属的回答进行了定量和定性分析。通过带有线性加权的格韦特AC1来评估认同程度。
在大多数预先指示中，其适用条件在预先写好的文本块中以宽泛、笼统的术语表述。50名患者中有23名（46%）死亡。所有亲属表示他们非常熟悉患者的意愿；19名亲属中有18名在法律上负责决策。在评估预先指示是否适用于当前情况时，医生与亲属之间以及两组医生之间的认同程度仅为一般且无统计学意义（0.35；95%置信区间[CI]：-0.01至0.71；p = 0.059）以及（0.24；95% CI：-0.03至0.50；p = 0.079）。亲属认为预先指示比医生认为的更有用（在从0[完全无用]到5[非常有用]的李克特量表上，中位数分别为5和3[p = 0.018]），并且倾向于逐字应用（在从0[倾向于医生的解释]到5[倾向于逐字应用]的李克特量表上，中位数分别为5和4[p = 0.018]）。决策30天后，13名亲属（68%）觉得患者的意愿得到了充分遵从。
这些群体对预先指示适用性的明显不同评估意味着当前最常见类型的预先指示不适用于重症监护。为了支持患者亲属作为决策替代参与者的角色，应制定改进后的预先指示，并将其实施纳入重症监护医生的培训和继续医学教育中。
