a Seattle Children's Hospital.
b University of Pennsylvania.
Am J Bioeth. 2018 Jan;18(1):3-11. doi: 10.1080/15265161.2017.1401157.
Clinicians at quaternary centers see part of their mission as providing hope when others cannot. They tend to see sicker patients with more complex disease processes. Part of this mission is offering longshot treatment modalities that are unlikely to achieve their stated goal, but conceivably could. When patients embark on such a treatment plan, it may fail. Often treatment toward an initial goal continues beyond the point at which such a goal is feasible. We explore the progression of care from longshot to fantasy using two pediatric cases. This progression may be differentiated into four distinct stages of care related to the potential of achieving the initial goals of care. Physicians are often ill prepared for the progression of treatments from a longshot hope to an unfeasible and, therefore, typically unjustified intervention. We present a structured approach to guide clinicians at referral institutions where these situations may be common. The transition of care from "longshot" to "fantasy" is an inherent part of quaternary care for the sickest of patients that has been underexplored. Physicians are often poorly equipped to approach that transition. We advocate this approach to the shift from longshot to fantasy with the belief that such a structured method will have multiple benefits, including: reduced suffering for the patient; decreased emotional burden on patient and family; decreased provider moral distress; increased likelihood of seeking high quality palliative care earlier; and provision of honest and straightforward information to patients and their families.
四级医疗机构的临床医生的使命之一是在他人无能为力时提供希望。他们倾向于治疗病情更严重、疾病过程更复杂的患者。这项使命的一部分是提供不太可能实现既定目标但有可能实现的治疗方法。当患者开始这种治疗计划时，它可能会失败。通常，朝着初始目标的治疗会持续到该目标可行的点之后。我们使用两个儿科病例来探讨从希望渺茫到幻想的治疗进展。这种进展可以分为四个不同的护理阶段，与实现护理初始目标的可能性有关。医生通常对从希望渺茫的治疗到不切实际且因此通常没有正当理由的干预的治疗进展准备不足。我们提出了一种结构化方法，为可能经常出现这种情况的转诊机构的临床医生提供指导。对于最病重的患者来说，从“希望渺茫”到“幻想”的治疗过渡是四级医疗的固有部分，但尚未得到充分探索。医生通常很难应对这种过渡。我们提倡这种从希望渺茫到幻想的治疗转变的方法，相信这种结构化方法将带来多种好处，包括：减轻患者的痛苦；减轻患者和家属的情绪负担；减少提供者的道德困境；增加尽早寻求高质量姑息治疗的可能性；并为患者及其家属提供诚实和直接的信息。
