Wheaton College, Norton, Massachusetts, USA.
ThinkerAnalytix, Cambridge, Massachusetts, USA.
J Med Philos. 2022 May 11;47(2):293-310. doi: 10.1093/jmp/jhab050.
Respect for patient autonomy can apply at two levels: ensuring that patient care reflects their considered values and wishes and honoring patient preferences about how to make momentous decisions. Caregivers who seek to respect patient autonomy in the context of some end-of-life decisions face a dilemma. Because these decisions are fraught, patients may prefer to approach them sequentially, only making decisions at the time they arise. However, respecting patients' preferences for a sequential approach can increase the likelihood that surrogates and care teams wind up in situations in which they lack information needed to ensure patients receive care that conforms to their considered values after they are no longer competent to make decisions for themselves. Sequential decision-making can thus conflict with the goal of ensuring care reflects the wishes of patients. After illustrating how this dilemma can arise in the use of life-sustaining "bridge" technologies, we argue that care teams may be warranted in requiring patients to articulate their wishes in an advance care plan before treatment begins. In some cases, care teams may even be permitted to refuse to undertake certain courses of care, unless patients articulate their wishes in an advance care plan.
确保患者护理反映他们经过深思熟虑的价值观和意愿，并尊重患者在做出重大决策时的偏好。在某些临终决策的背景下，寻求尊重患者自主权的护理人员面临两难境地。由于这些决策充满风险，患者可能更愿意按顺序处理这些决策，只在出现时做出决策。然而，尊重患者对顺序方法的偏好可能会增加代理人和护理团队在缺乏必要信息的情况下陷入困境的可能性，这些信息是确保在患者丧失决策能力后，为他们提供符合其深思熟虑的价值观的护理所必需的。因此，顺序决策可能与确保护理反映患者意愿的目标相冲突。在说明了这个困境如何在使用维持生命的“桥梁”技术时出现之后，我们认为，在治疗开始之前，护理团队可能有理由要求患者在预先护理计划中阐明他们的意愿。在某些情况下，护理团队甚至可以被允许拒绝提供某些护理课程，除非患者在预先护理计划中阐明了他们的意愿。
