Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston.
Fostering Improvement in End-of-Life Decision Science, University of Pennsylvania, Philadelphia.
JAMA Netw Open. 2019 Jan 4;2(1):e187851. doi: 10.1001/jamanetworkopen.2018.7851.
Patients with serious illnesses are often encouraged to actively deliberate about the desirability of life support. Yet it is unknown whether deliberation changes the substance or quality of such decisions.
To identify differences in decisions about life support interventions and goals of care made intuitively vs deliberatively by patients with serious illnesses.
DESIGN, SETTING, AND PARTICIPANTS: Randomized clinical trial in which patients were asked to express treatment preferences in a series of clinical scenarios. Participants were 199 hospitalized patients aged 60 years and older with serious oncologic, cardiac, and pulmonary illnesses treated in a large, urban academic hospital from July 1, 2015, through March 15, 2016.
Patients in the intuitive group were subjected to a cognitive load and instructed to answer each question immediately based on gut instinct. Patients in the deliberative group were not cognitively loaded, were instructed to think carefully about their answers, and were required to explain their answers.
Choices regarding life support (4 scenarios) and goals of care (1 scenario), concordance of these choices with patients' valuations of health states that could follow from them, and decisional uncertainty.
Of 199 patients, 132 (66%) were male and the mean (SD) age was 67.2 (5.0) years. Similar proportions of patients in the intuitive group (n = 97) and the deliberative group (n = 102) said they would accept a feeding tube for chronic aspiration (42% vs 44%, respectively; difference, -2%; 95% CI, -16% to 12%; P = .79), antibiotics for life-threatening infection in the event of terminal illness (39% vs 43%, respectively; difference, -4%; 95% CI, -18% to 10%; P = .57), a trial of mechanical ventilation (59% vs 60%, respectively; difference,-1%; 95% CI, -15% to 13%; P = .88), and a tracheostomy tube (37% vs 41%, respectively; difference, -4%; 95% CI, -22% to 13%; P = .64). Patients in the deliberative group were slightly more likely than patients in the intuitive group to choose a palliative approach to treatment in the event of serious illness (45% vs 30%, respectively; difference, 15%; 95% CI, 1%-29%; P = .04). Across scenarios, decisional uncertainty was similar between the 2 groups (all P > .05), and intuitive decisions were either equally or more closely aligned with patients' health state valuations than deliberative decisions.
In this study, encouraging hospitalized patients with serious illnesses to deliberate on end-of-life decisions did not change the content or improve the quality of these decisions. It is important to evaluate whether decision aids and structured communication interventions improve seriously ill patients' choices.
ClinicalTrials.gov Identifier: NCT02487810.
通常鼓励患有严重疾病的患者积极考虑生命支持的可取性。然而，尚不清楚审议是否会改变此类决策的实质或质量。
确定通过深思熟虑与直觉做出的生命支持干预和护理目标决策之间的差异，这些决策是由患有严重疾病的患者做出的。
设计、设置和参与者：这是一项随机临床试验，要求参与者在一系列临床情景中表达治疗偏好。参与者为 199 名年龄在 60 岁及以上的住院患者，患有严重的肿瘤、心脏和肺部疾病，在一家大型城市学术医院接受治疗，时间为 2015 年 7 月 1 日至 2016 年 3 月 15 日。
直觉组的患者会受到认知负荷的影响，并被要求根据直觉立即回答每个问题。深思熟虑组的患者不会受到认知负荷的影响，他们被要求仔细考虑自己的答案，并要求他们解释自己的答案。
关于生命支持（4 个场景）和护理目标（1 个场景）的选择，这些选择与患者对可能随之而来的健康状况的评估的一致性，以及决策不确定性。
在 199 名患者中，有 132 名（66%）为男性，平均（SD）年龄为 67.2（5.0）岁。直觉组（n=97）和深思熟虑组（n=102）的患者表示他们将接受慢性吸入性肺炎的饲管的比例相似（分别为 42%和 44%；差异，-2%；95%置信区间，-16%至 12%；P=0.79）、危及生命的感染时使用抗生素（分别为 39%和 43%；差异，-4%；95%置信区间，-18%至 10%；P=0.57）、机械通气试验（分别为 59%和 60%；差异，-1%；95%置信区间，-15%至 13%；P=0.88）和气管造口管（分别为 37%和 41%；差异，-4%；95%置信区间，-22%至 13%；P=0.64）。深思熟虑组的患者比直觉组的患者更倾向于在患有严重疾病时选择姑息治疗方法（分别为 45%和 30%；差异，15%；95%置信区间，1%至 29%；P=0.04）。在所有场景中，两组之间的决策不确定性相似（均 P>0.05），并且直觉决策与患者的健康状况评估更加一致或更接近。
在这项研究中，鼓励患有严重疾病的住院患者仔细考虑临终决策并没有改变这些决策的内容或提高这些决策的质量。评估决策辅助工具和结构化沟通干预措施是否可以改善严重疾病患者的选择非常重要。
ClinicalTrials.gov 标识符：NCT02487810。
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