Schoene-Seifert Bettina, Uerpmann Anna Lena, Gerß Joachim, Herr David
Institute for Ethics, History, and Theory of Medicine, Westfaelische Wilhelms-Universitaet, Muenster, Germany.
Clinic of Psychiatry and Psychotherapy, Ev. Hospital Bielefeld, Bielefeld, Germany.
J Am Med Dir Assoc. 2016 Apr 1;17(4):294-9. doi: 10.1016/j.jamda.2016.01.014. Epub 2016 Feb 26.
Whether health care professionals should respect a properly executed advance directive (AD) refusing life support in late-stage dementia even if the patient seems contented, is an ethically contested issue. We undertook a nationwide survey to assess this problem and to test a practical solution.
Nationwide survey using a questionnaire among 4 stakeholder groups.
Germany.
Adult Germans (n = 735), among them: dementia-experienced physicians (n = 161), dementia-experienced nurses (n = 191), next of kin (n = 197), and dementia-inexperienced adults (n = 186).
Participants were asked about their attitudes on medical decision-making in a vignette case of treatable pneumonia, for their agreement or disagreement on standard ethical arguments in this debate, and for their views on modified versions of the case. One such modification was an explicit anticipation of the conflict in question by the patients themselves.
Of our 735 eligible respondents, 25% were unwilling to follow the patient's AD. Standard arguments for and against respecting the directive were endorsed to different degrees. Respondents' unwillingness to follow the directive was significantly decreased (to 16.3%, P < .001), if the advance refusal of pneumonia treatment explicitly indicated that it applied to a patient who appears content in his demented state. Only 8.7% of respondents would disregard an advance refusal of tube feeding.
Persons executing ADs forbidding life support in late-stage dementia run some risk that these will not be followed if they later appear "happy" in their dementia. It seems ethically and practically advisable to incorporate an explicit meta-directive for this conflict.
即便患者看似心满意足，医护人员是否应尊重一份执行妥当的预先医疗指示（AD），拒绝为晚期痴呆患者提供生命支持，这是一个存在伦理争议的问题。我们开展了一项全国性调查来评估这一问题，并测试一种切实可行的解决方案。
对4个利益相关者群体进行全国性问卷调查。
德国。
成年德国人（n = 735），其中：有痴呆症护理经验的医生（n = 161）、有痴呆症护理经验的护士（n = 191）、近亲（n = 197）以及无痴呆症护理经验的成年人（n = 186）。
向参与者询问他们在一个可治疗肺炎的案例中的医疗决策态度，询问他们对该辩论中标准伦理观点的同意或不同意情况，以及他们对该案例修改版本的看法。其中一种修改是让患者自己明确预见到相关冲突。
在我们的735名合格受访者中，25%的人不愿意遵循患者的预先医疗指示。支持和反对遵循该指示的标准观点得到了不同程度的认可。如果预先拒绝肺炎治疗明确表明适用于处于痴呆状态却看似心满意足的患者，受访者不遵循该指示的意愿会显著降低（降至16.3%，P < .001）。只有8.7%的受访者会无视预先拒绝鼻饲的指示。
签署预先医疗指示禁止在晚期痴呆时提供生命支持的人存在一定风险，即如果他们后来在痴呆状态下显得“开心”，这些指示可能不会得到遵循。从伦理和实际角度来看，纳入针对这一冲突的明确元指示似乎是可取的。
