1 School of Nursing, Case Western Reserve University, Cleveland, OH, USA.
2 School of Medicine, Case Western Reserve University, Cleveland, OH, USA.
J Intensive Care Med. 2018 Oct;33(10):557-566. doi: 10.1177/0885066616678394. Epub 2016 Nov 20.
Despite multiple trials of interventions to improve end-of-life care of the critically ill, there is a persistent lack of understanding of factors associated with barriers to decision-making at the end of life.
To apply the principles of complexity science in examining the extent to which transitions to end-of-life care can be predicted by physician, family, or patient characteristics; outcome expectations; and the evaluation of treatment effectiveness.
A descriptive, longitudinal study was conducted in 3 adult intensive care units (ICUs). Two hundred sixty-four family surrogates of patients lacking decisional capacity and the physicians caring for the patients were interviewed every 5 days until ICU discharge or patient death.
Characteristics of patients, physicians, and family members; values and preferences of physicians and family; and evaluation of treatment effectiveness, expectations for patient outcomes, and relative priorities in treatment (comfort vs survival). The primary outcome, focus of care, was categorized as (1) maintaining a survival orientation (no treatment limitations), (2) transitioning to a stronger palliative focus (eg, some treatment limitations), or (3) transitioning to an explicit end-of-life, comfort-oriented care plan.
Physician expectations for survival and future cognitive status were the only variables consistently and significantly related to the focus of care. Neither physician or family evaluations of treatment effectiveness nor what was most important to physicians or family members was influential.
Lack of influence of family and physician views, in comparison to the consistent effect of survival probabilities, suggests barriers to incorporation of individual values in treatment decisions.
尽管已经进行了多次尝试来改善危重病患者的临终关怀，但对于与临终决策障碍相关的因素，仍缺乏了解。
应用复杂性科学的原理，考察医生、家庭或患者特征、预后期望以及治疗效果评估等因素在多大程度上可以预测向临终关怀的转变。
在 3 个成人重症监护病房（ICU）中进行了一项描述性、纵向研究。对 264 名丧失决策能力的患者的家属代理人以及照顾患者的医生进行了每 5 天一次的访谈，直至 ICU 出院或患者死亡。
患者、医生和家庭成员的特征；医生和家属的价值观和偏好；以及治疗效果评估、对患者预后的期望以及治疗的相对优先级（舒适度与生存）。主要结局指标，即关注焦点，分为（1）保持生存取向（无治疗限制），（2）向更强的姑息治疗方向转变（例如，有一些治疗限制），或（3）向明确的临终、舒适导向的护理计划转变。
医生对生存和未来认知状态的期望是唯一与关注焦点始终一致且显著相关的变量。医生或家属对治疗效果的评估，以及医生或家属认为最重要的内容，都没有影响。
与生存概率的持续影响相比，家庭和医生观点的影响较小，表明在治疗决策中纳入个体价值观存在障碍。
