Erel Meira, Marcus Esther-Lee, DeKeyser Ganz Freda
Henrietta Szold Hadassah-Hebrew University School of Nursing, Jerusalem, Israel.
Division of Geriatrics, Herzog Medical Center, Jerusalem, Israel.
Front Med (Lausanne). 2023 Jun 22;10:1145142. doi: 10.3389/fmed.2023.1145142. eCollection 2023.
Palliative care (PC) delivery for persons with advanced dementia (AD) remains low, particularly in acute-care settings. Studies have shown that cognitive biases and moral characteristics can influence patient care through their effect on the thinking patterns of healthcare workers (HCWs). This study aimed to determine whether cognitive biases, including representativeness, availability, and anchoring, are associated with treatment approaches, ranging from palliative to aggressive care in acute medical situations, for persons with AD.
Three hundred fifteen HCWs participated in this study: 159 physicians and 156 nurses from medical and surgical wards in two hospitals. The following questionnaires were administered: a socio-demographic questionnaire; the Moral Sensitivity Questionnaire; the Professional Moral Courage Scale; a case scenario of a person with AD presenting with pneumonia, with six possible interventions ranging from PC to aggressive care (referring to life-prolonging interventions), each given a score from (-1) (palliative) to 3 (aggressive), the sum of which is the "Treatment Approach Score;" and 12 items assessing perceptions regarding PC for dementia. Those items, the moral scores, and professional orientation (medical/surgical) were classified into the three cognitive biases.
The following aspects of cognitive biases were associated with the Treatment Approach Score: representativeness-agreement with the definition of dementia as a terminal disease and appropriateness of PC for dementia; availability-perceived organizational support for PC decisions, apprehension regarding response to PC decisions by seniors or family, and apprehension regarding a lawsuit following PC; and anchoring-perceived PC appropriateness by colleagues, comfort with end-of-life conversations, guilt feelings following the death of a patient, stress, and avoidance accompanying care. No association was found between moral characteristics and the treatment approach. In a multivariate analysis, the predictors of the care approach were: guilt feelings about the death of a patient, apprehension regarding senior-level response, and PC appropriateness for dementia.
Cognitive biases were associated with the care decisions for persons with AD in acute medical conditions. These findings provide insight into the potential effects of cognitive biases on clinical decisions, which may explain the disparity between treatment guidelines and the deficiency in the implementation of palliation for this population.
为晚期痴呆症（AD）患者提供姑息治疗（PC）的比例仍然很低，尤其是在急性护理环境中。研究表明，认知偏差和道德特征可通过影响医护人员（HCW）的思维模式来影响患者护理。本研究旨在确定认知偏差，包括代表性、可得性和锚定，是否与AD患者在急性医疗情况下从姑息治疗到积极治疗的治疗方法相关。
315名医护人员参与了本研究：来自两家医院内科和外科病房的159名医生和156名护士。发放了以下问卷：一份社会人口学问卷；道德敏感性问卷；职业道德勇气量表；一个AD患者患肺炎的病例场景，有六种可能的干预措施，从姑息治疗到积极治疗（指延长生命的干预措施），每种措施的评分从（-1）（姑息）到3（积极），其总和为“治疗方法得分”；以及12项评估对痴呆症姑息治疗看法的项目。这些项目、道德得分和专业方向（内科/外科）被分类为三种认知偏差。
认知偏差的以下方面与治疗方法得分相关：代表性——认同痴呆症为终末期疾病的定义以及姑息治疗对痴呆症的适用性；可得性——对姑息治疗决策的组织支持感、对上级或家属对姑息治疗决策反应的担忧以及对姑息治疗后诉讼的担忧；以及锚定——同事对姑息治疗适用性的认知、对临终谈话的舒适度、患者死亡后的内疚感、压力以及护理伴随的回避。未发现道德特征与治疗方法之间存在关联。在多变量分析中，护理方法的预测因素为：对患者死亡的内疚感、对上级反应的担忧以及姑息治疗对痴呆症的适用性。
认知偏差与急性医疗状况下AD患者的护理决策相关。这些发现为认知偏差对临床决策的潜在影响提供了见解，这可能解释了治疗指南与该人群姑息治疗实施不足之间的差异。
