Department of Medicine, Northwestern University, Chicago, IL.
Department of Medical Social Sciences, Northwestern University, Chicago, IL.
Crit Care Med. 2019 Jun;47(6):784-791. doi: 10.1097/CCM.0000000000003711.
Shared decision-making is recommended for critically ill adults who face major, preference-sensitive treatment decisions. Yet, little is known about when and how patients and families are engaged in treatment decision-making over the longitudinal course of a critical illness. We sought to characterize patterns of treatment decision-making by evaluating clinician discourse in the electronic health record of critically ill adults who develop chronic critical illness or die in an ICU.
DESIGN, SETTING, AND PATIENTS: We conducted qualitative content analysis of the electronic health record of 52 adult patients, admitted to a medical ICU in a tertiary medical center from January 1, 2016, to December 31, 2016. We included patients who met a consensus definition of chronic critical illness (26 patients) and a matched sample who died or transitioned to hospice care in the ICU before developing chronic critical illness (26 patients).
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Characterization of clinician decision-making discourse documented during the course of an ICU stay. Clinician decision-making discourse in the electronic health record followed a single, consistent pattern across both groups. Initial decisions about admission to the ICU focused on specific interventions that can only be provided in an ICU environment (intervention-focused decisions). Following admission, the documented rationale for additional treatments was guided by physiologic abnormalities (physiology-centered decisions). Clinician discourse transitioned to documented engagement of patients and families in decision-making when treatments failed to achieve specified physiologic goals. The phrase "goals of care" is common in the electronic health record and is used to indicate poor prognosis, to describe conflict with families, and to provide rationale for treatment limitations.
Clinician discourse in the electronic health record reveals that patient physiology strongly guides treatment decision-making throughout the longitudinal course of critical illness. Documentation of patient and family engagement in treatment decision-making is limited until available medical treatments fail to achieve physiologic goals.
对于面临重大、偏好敏感的治疗决策的重症成人患者，推荐采用共同决策。然而，对于患者和家属在重症疾病的纵向病程中何时以及如何参与治疗决策，知之甚少。我们试图通过评估在 ICU 中发展为慢性重病或死亡的重症成人患者的电子健康记录中的临床医生话语来描述治疗决策模式。
设计、地点和患者：我们对 2016 年 1 月 1 日至 12 月 31 日期间在一家三级医疗中心的内科 ICU 住院的 52 名成年患者的电子健康记录进行了定性内容分析。我们纳入了符合慢性重病共识定义的患者（26 例）和在发展为慢性重病之前在 ICU 死亡或过渡到临终关怀的匹配样本（26 例）。
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描述 ICU 住院期间临床医生决策话语的特征。电子健康记录中的临床医生决策话语在两组中都遵循单一、一致的模式。最初决定入住 ICU 侧重于只能在 ICU 环境中提供的特定干预措施（以干预为重点的决策）。入院后，额外治疗的记录理由由生理异常指导（以生理为中心的决策）。当治疗未能达到特定的生理目标时，临床医生的话语会转变为记录患者和家属参与决策。“治疗目标”一词在电子健康记录中很常见，用于表示预后不良、描述与家属的冲突以及为治疗限制提供理由。
电子健康记录中的临床医生话语表明，患者的生理状况在重症疾病的纵向病程中强烈指导着治疗决策。只有在可用的医疗治疗未能达到生理目标时，才会记录患者和家属参与治疗决策。
