Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
Department of Engineering and Public Policy, Carnegie Mellon University, Pittsburgh, PA; Global Health Research Center, Duke Kunshan University, Suzhou, China.
Resuscitation. 2024 Jun;199:110226. doi: 10.1016/j.resuscitation.2024.110226. Epub 2024 Apr 27.
Perceived poor prognosis can lead to withdrawal of life-sustaining therapies (WLST) in patients who might otherwise recover. We characterized clinicians' approach to post-arrest prognostication in a multicenter clinical trial.
Semi-structured interviews were conducted with clinicians who treated a comatose post-cardiac arrest patient enrolled in the Influence of Cooling Duration on Efficacy in Cardiac Arrest Patients (ICECAP) trial (NCT04217551). Two authors independently analyzed each interview using inductive and deductive coding. The clinician reported how they arrived at a prognosis for the specific patient. We summarized the frequency with which clinicians reported using objective diagnostics to formulate their prognosis, and compared the reported approaches to established guidelines. Each respondent provided demographic information and described local neuroprognostication practices.
We interviewed 30 clinicians at 19 US hospitals. Most claimed adherence to local hospital neuroprognostication protocols (n = 19). Prognostication led to WLST for perceived poor neurological prognosis in 15/30 patients, of whom most showed inconsistencies with guidelines or trial recommendations, respectively. In 10/15 WLST cases, clinicians reported relying on multimodal testing. A prevalent theme was the use of "clinical gestalt," defined as prognosticating based on a patient's overall appearance or a subjective impression in the absence of objective data. Many clinicians (21/30) reported using clinical gestalt for initial prognostication, with 9/21 expressing high confidence initially.
Clinicians in our study state they follow neuroprognostication guidelines in general but often do not do so in actual practice. They reported clinical gestalt frequently informed early, highly confident prognostic judgments, and few objective tests changed initial impressions. Subjective prognostication may undermine well-designed trials.
较差的预后感知可能导致原本有机会康复的患者撤停生命支持治疗（WLST）。我们在一项多中心临床试验中对临床医生在心脏骤停后预后预测的方法进行了特征描述。
对参与 Influence of Cooling Duration on Efficacy in Cardiac Arrest Patients（ICECAP）试验（NCT04217551）的昏迷心脏骤停患者进行治疗的临床医生进行了半结构化访谈。两位作者分别使用归纳和演绎编码方法独立分析了每次访谈。临床医生报告了他们如何为特定患者得出预后。我们总结了临床医生报告使用客观诊断来制定预后的频率，并将报告的方法与既定指南进行了比较。每位受访者提供了人口统计学信息，并描述了当地神经预后判断的实践情况。
我们在 19 家美国医院采访了 30 名临床医生。大多数人声称遵守当地医院神经预后判断的协议（n=19）。在 30 名患者中，有 15 名因感知到不良神经预后而进行 WLST，其中大多数人分别与指南或试验建议不一致。在 10/15 例 WLST 病例中，临床医生报告依赖于多模态测试。一个常见的主题是使用“临床整体观”，这是指在缺乏客观数据的情况下，根据患者的整体外观或主观印象进行预后判断。许多临床医生（30/30）报告说，他们在最初的预后判断中使用了临床整体观，其中 9/21 表示最初的信心很高。
我们研究中的临床医生表示，他们总体上遵循神经预后判断指南，但在实际实践中经常不遵循这些指南。他们报告说，临床整体观经常影响早期、高度自信的预后判断，很少有客观测试改变最初的印象。主观预后判断可能会破坏精心设计的试验。
