Ong Charlene J, Dhand Amar, Diringer Michael N
Department of Neurology, Washington University School of Medicine, 660 South Euclid Avenue, Box 8111, St. Louis, MO, 63110, USA.
Neurocrit Care. 2016 Oct;25(2):258-65. doi: 10.1007/s12028-016-0275-5.
Neurologists are often asked to define prognosis in comatose patients. However, comatose patients following cardiac arrest are usually cared for by cardiologists or intensivists, and it is their approach that will influence decisions regarding withdrawal of life-sustaining interventions (WLSI). We observed that factors leading to these decisions vary across specialties and considered whether they could result in self-fulfilling prophecies and early WLSI. We conducted a hypothesis-generating qualitative study to identify factors used by non-neurologists to define prognosis in these patients and construct an explanatory model for how early WLSI might occur.
This was a single-center qualitative study of intensivists caring for cardiac arrest patients with hypoxic-ischemic coma. Thirty attending physicians (n = 16) and fellows (n = 14) from cardiac (n = 8), medical (n = 6), surgical (n = 10), and neuro (n = 6) intensive care units underwent semi-structured interviews. Interview transcripts were analyzed using grounded theory techniques.
We found three components of early WLSI among non-neurointensivists: (1) development of fixed negative opinions; (2) early framing of poor clinical pictures to families; and (3) shortened windows for judging recovery potential. In contrast to neurointensivists, non-neurointensivists' negative opinions were frequently driven by patients' lack of consciousness and cardiopulmonary resuscitation circumstances. Both groups were influenced by age and comorbidities.
The results demonstrate that factors influencing prognostication differ across specialties. Some differ from those recommended by published guidelines and may lead to self-fulfilling prophecies and early WLSI. Better understanding of this framework would facilitate educational interventions to mitigate this phenomenon and its implications on patient care.
神经科医生经常被要求界定昏迷患者的预后。然而，心脏骤停后的昏迷患者通常由心脏病专家或重症监护医生负责护理，而正是他们的处理方式会影响关于撤除生命维持干预措施（WLSI）的决策。我们观察到，导致这些决策的因素在不同专业之间存在差异，并思考这些差异是否会导致自我实现的预言以及过早的WLSI。我们开展了一项产生假设的定性研究，以确定非神经科医生用于界定这些患者预后的因素，并构建一个关于过早WLSI可能如何发生的解释模型。
这是一项针对护理缺氧缺血性昏迷心脏骤停患者的重症监护医生的单中心定性研究。来自心脏（n = 8）、内科（n = 6）、外科（n = 10）和神经（n = 6）重症监护病房的30位主治医师（n = 16）和住院医师（n = 14）接受了半结构化访谈。访谈记录采用扎根理论技术进行分析。
我们发现非神经重症监护医生中过早WLSI的三个组成部分：（1）形成固定的负面看法；（2）向家属过早描绘不良临床情况；（3）判断恢复潜力的时间窗口缩短。与神经重症监护医生相比，非神经重症监护医生的负面看法经常由患者意识缺失和心肺复苏情况所驱动。两组都受到年龄和合并症的影响。
结果表明，影响预后判断的因素在不同专业之间存在差异。其中一些因素与已发表指南所推荐的因素不同，可能导致自我实现的预言和过早的WLSI。更好地理解这个框架将有助于开展教育干预措施，以减轻这种现象及其对患者护理的影响。
