Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace St. Scaife Hall, Room 608, HPU010604, Pittsburgh, 15261, PA, USA.
Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, PA, USA.
Crit Care. 2023 Feb 16;27(1):61. doi: 10.1186/s13054-023-04332-w.
Whether surrogate decision makers regret decisions about the use of life support for incapacitated, critically ill patients remain uncertain. We sought to determine the prevalence of decision regret among surrogates of adult ICU patients and identify factors that influence regret.
We conducted a secondary analysis of data from the PARTNER 2 trial, which tested a family support intervention for surrogates of critically ill adults. At 6-month follow-up, surrogates rated their regret about life support decisions using the Decision Regret Scale (DRS), scored from 0 to 100, with higher scores indicating more regret. We used multiple linear regression to identify covariates associated with decision regret based on a psychological construct of regret. We constructed two models using the full cohort; model 1 included patient outcomes; model 2 focused on covariates known at the time of ICU decision-making. Subgroup analyses were also conducted based on patient survival status at hospital discharge and 6-month follow-up.
748 of 848 surrogates had complete DRS data. The median (IQR) DRS score was 15 (0, 25). Overall, 54% reported mild regret (DRS 5-25), 19% moderate-strong regret (DRS 30-100), and 27% no regret (DRS 0). Poor patient outcome at 6 months (death or severe functional dependence) was associated with more regret in model 1 (β 10.1; 95% C.I. 3.2, 17.0). In model 2, palliative care consultation (3.0; 0.1, 5.9), limitations in life support (LS) prior to death (6.3; 3.1, 9.4) and surrogate black race (6.3; 0.3, 12.3) were associated with more regret. Other modulators of regret in subgroup analyses included surrogate age and education level, surrogate-patient relationship, death in hospital (compared to the post-discharge period), and code status at time of ICU admission.
One in five ICU surrogate decision makers experience moderate to strong regret about life support decisions in ICU. Poor patient outcomes are linked to more regret. Decisions to limit life support prior to patient death may also increase regret. Future studies are needed to understand how regret relates to decision quality and how to lessen lasting regret.
对于丧失能力的重症患者，代理决策者对使用生命支持的决策是否感到后悔仍不确定。我们旨在确定成人 ICU 患者的代理人中后悔决策的普遍程度，并确定影响后悔的因素。
我们对 PARTNER 2 试验的数据进行了二次分析，该试验测试了一种针对重症成人代理人的家庭支持干预措施。在 6 个月的随访中，代理人使用决策后悔量表（DRS）对生命支持决策的后悔程度进行评分，分值范围为 0 到 100，得分越高表示后悔程度越高。我们使用多元线性回归根据后悔的心理结构确定与决策后悔相关的协变量。我们使用完整队列构建了两个模型；模型 1 纳入了患者结局；模型 2 则侧重于 ICU 决策时已知的协变量。我们还根据患者出院时和 6 个月随访时的生存状况进行了亚组分析。
848 名代理人中的 748 名完成了 DRS 数据。DRS 中位数（IQR）为 15（0，25）。总体而言，54%的人报告轻微后悔（DRS 5-25），19%的人报告中度至强烈后悔（DRS 30-100），27%的人报告无后悔（DRS 0）。6 个月时患者结局较差（死亡或严重功能依赖）与模型 1 中的更多后悔相关（β 10.1；95%置信区间 3.2，17.0）。在模型 2 中，临终关怀咨询（3.0；0.1，5.9）、死亡前生命支持（LS）受限（6.3；3.1，9.4）和代理黑人种族（6.3；0.3，12.3）与更多的后悔有关。后悔的其他调节剂在亚组分析中包括代理人年龄和教育水平、代理人与患者的关系、医院内死亡（与出院后时期相比）和 ICU 入院时的编码状态。
五分之一的 ICU 代理决策者对 ICU 中的生命支持决策感到中度至强烈的后悔。患者结局较差与更多的后悔相关。在患者死亡前决定限制生命支持也可能会增加后悔。需要进一步研究来了解后悔与决策质量的关系以及如何减轻持久的后悔。
