Cardona Magnolia, Anstey Matthew, Lewis Ebony T, Shanmugam Shantiban, Hillman Ken, Psirides Alex
Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Robina, Australia.
Gold Coast Hospital and Health Service, Southport, Australia.
Breathe (Sheff). 2020 Jun;16(2):200062. doi: 10.1183/20734735.0062-2020.
The patient and family perspective on the appropriateness of intensive care unit (ICU) treatments involves preferences, values and social constructs beyond medical criteria. The clinician's perception of inappropriateness is more reliant on clinical judgment. Earlier consultation with families before ICU admission and patient education on the outcomes of life-sustaining therapies may help reconcile these provider-patient disagreements. However, global emergencies like COVID-19 change the usual paradigm of end-of-life care, as it is a new disease with only scarce predictive information about it. Pandemics can also bring about the burdensome predicament of doctors having to make unwanted choices of rationing access to the ICU when demand for otherwise life-saving resources exceeds supply. Evidence-based prognostic checklists may guide treatment triage but the principles of shared decision-making are unchanged. Yet, they need to be altered with respect to COVID-19, defining likely outcomes and likelihood of benefit for the patient, and clarifying their willingness to take on the risks inherent to being in an ICU for 2 weeks for those eligible. For patients who are admitted during the prodrome of COVID-19 disease, or those who deteriorate in the second week, clinicians have some lead time in hospital to have appropriate discussions about ceilings of treatments offered based on severity.
The patient and family perspective on inappropriateness of intensive care at the end of life often differs from the clinician's opinion due to the nonmedical frame of mind.To improve satisfaction with communication on treatment goals, consultation on patient values and inclusion of social constructs in addition to clinical prediction is a good start to reconcile differences between physician and health service users' viewpoints.During pandemics, where health systems may collapse, different admission criteria driven by the need to ration services may be warranted.
To explore the extent to which older patients and their families are involved in decisions about appropriateness of intensive care admission or treatmentsTo understand how patients or their families define inappropriate intensive care admission or treatmentsTo reflect on the implications of decision to admit or not to admit to the intensive care unit in the face of acute resource shortages during a pandemic.
患者及其家属对重症监护病房（ICU）治疗适宜性的看法涉及医疗标准之外的偏好、价值观和社会观念。临床医生对不适宜性的认知更多地依赖于临床判断。在患者入住ICU之前尽早与家属进行沟通，并对维持生命治疗的结果对患者进行教育，可能有助于调和医患之间的这些分歧。然而，像新冠疫情这样的全球紧急情况改变了临终关怀的常规模式，因为这是一种新出现的疾病，关于它的预测信息非常有限。疫情还可能导致医生面临艰难困境，即当对原本可挽救生命的资源需求超过供应时，不得不做出限制ICU准入的无奈选择。基于证据的预后清单可能有助于指导治疗分诊，但共同决策的原则并未改变。然而，对于新冠疫情，这些原则需要进行调整，明确患者可能的预后和获益可能性，并向符合条件的患者阐明他们愿意承担在ICU接受两周治疗所固有的风险。对于在新冠疾病前驱期入院的患者，或在第二周病情恶化的患者，临床医生在医院有一些时间，可以根据病情严重程度就所提供治疗的上限进行适当讨论。
由于思维的非医学性，患者及其家属对临终时重症监护不适宜性的看法往往与临床医生的意见不同。为提高对治疗目标沟通的满意度，除了临床预测外，就患者价值观进行咨询并纳入社会观念，是调和医生与医疗服务使用者观点差异的良好开端。在疫情期间，卫生系统可能崩溃，因资源配给需要而采用不同的入院标准可能是必要的。
探讨老年患者及其家属在重症监护入院或治疗适宜性决策中的参与程度；了解患者及其家属如何界定不适当的重症监护入院或治疗；思考在疫情期间急性资源短缺情况下决定是否入住重症监护病房的影响。
