Seidlein Anna-Henrikje, Hannich Arne, Nowak Andre, Gründling Matthias, Salloch Sabine
Institute of Ethics and History of Medicine, University Medicine Greifswald, Greifswald, Germany.
Institute for History and Ethics of Medicine, Martin Luther University Halle-Wittenberg, Halle(Saale), Germany.
J Med Ethics. 2020 Apr 24. doi: 10.1136/medethics-2019-105752.
The decision-making environment in intensive care units (ICUs) is influenced by the transformation of intensive care medicine, the staffing situation and the increasing importance of patient autonomy. Normative implications of time in intensive care, which affect all three areas, have so far barely been considered. The study explores patterns of decision making concerning the continuation, withdrawal and withholding of therapies in intensive care. A triangulation of qualitative data collection methods was chosen. Data were collected through non-participant observation on a surgical ICU at an academic medical centre followed by semi-structured interviews with nurses and physicians. The transcribed interviews and observation notes were coded and analysed using qualitative content analysis according to Mayring. Three themes related to time emerged regarding the escalation or de-escalation of therapies: influence of time on prognosis, time as a scarce resource and timing in regards to decision making. The study also reveals the ambivalence of time as a norm for decision making. The challenge of dealing with time-related efforts in ICU care results from the tension between the need to wait to optimise patient care, which must be balanced against the significant time pressure which is characteristic of the ICU setting.
重症监护病房（ICU）的决策环境受到重症监护医学的变革、人员配备情况以及患者自主权日益重要性的影响。重症监护中的时间规范影响着所有这三个领域，但迄今为止几乎未被考虑。该研究探讨了重症监护中关于治疗延续、撤减和 withholding 的决策模式。研究选择了定性数据收集方法的三角测量法。通过在一所学术医疗中心的外科重症监护病房进行非参与观察，随后对护士和医生进行半结构化访谈来收集数据。根据迈林的方法，对转录的访谈和观察笔记进行编码并使用定性内容分析进行分析。关于治疗的升级或降级出现了三个与时间相关的主题：时间对预后的影响、时间作为一种稀缺资源以及决策的时机。该研究还揭示了时间作为决策规范的矛盾性。在重症监护护理中应对与时间相关的工作所面临的挑战源于等待以优化患者护理的需求与重症监护环境特有的巨大时间压力之间的紧张关系。 （注：原文中“withholding”直译为“ withholding”，结合语境这里可能是指“停止给予（治疗等）”，但在中文表达中较难找到完全对应的简洁表述，暂保留英文供参考理解。）
