Christine E. DeForge is a postdoctoral research fellow, Columbia University School of Nursing, New York, New York.
Arlene Smaldone is a professor of nursing, Columbia University Irving Medical Center, New York, New York.
Am J Crit Care. 2024 Nov 1;33(6):433-445. doi: 10.4037/ajcc2024211.
Surrogates of incapacitated patients in the intensive care unit (ICU) face decisions related to life-sustaining treatments. Decisional conflict is understudied.
To compare experiences of ICU surrogates by reported level of decisional conflict related to treatment decisions after a patient's cardiac arrest preceding death.
Convergent mixed methods were used. Bereaved surrogates recruited from a single northeastern US academic medical center completed surveys including the low-literacy Decisional Conflict Scale (moderate-to-high cut point >25) and individual interviews about 1 month after the patient's death. Interview data were analyzed by directed and conventional content analysis. Surrogates were stratified by median total survey score, and interview findings were compared by decisional conflict level.
Of 16 surrogates, 7 reported some decisional conflict (median survey score, 0; range, 0-25). About two-thirds decided to withdraw treatments. Three themes emerged from interviews: 2 reflecting decision-making experiences ("the ultimate act"; "the legacy of clinician communication") and 1 reflecting bereavement experiences ("I wish there was a handbook"). Surrogates reporting decisional conflict included those who first pursued but later withdrew treatments after a patient's in-hospital cardiac arrest. Surrogates with decisional conflict described suboptimal support, poor medical understanding, and lack of clarity about patients' treatment preferences.
These findings provide insight into bereaved ICU surrogates' experiences. The low overall survey scores may reflect retrospective measurement. Surrogates who pursued treatment were underrepresented. Novel approaches to support bereaved surrogates are warranted.
在重症监护病房（ICU）中，无法做出决策的患者的代理人面临与维持生命的治疗相关的决策。决策冲突研究不足。
通过比较患者心脏骤停后死亡前与治疗决策相关的报告决策冲突水平，比较 ICU 代理人的经验。
采用汇聚式混合方法。从美国东北部的一家学术医疗中心招募的失去亲人的代理人在患者死亡后大约 1 个月完成了包括低识字量决策冲突量表（中度至高度切点>25）和个人访谈的调查。访谈数据通过定向和常规内容分析进行分析。代理人根据总调查评分中位数进行分层，根据决策冲突水平比较访谈结果。
在 16 名代理人中，有 7 名报告存在一定程度的决策冲突（中位数调查评分，0；范围，0-25）。约三分之二的人决定撤回治疗。访谈中出现了三个主题：2 个反映决策制定经验（“最终行为”；“临床医生沟通的遗产”）和 1 个反映丧亲经验（“我希望有一本手册”）。报告有决策冲突的代理人包括那些在患者院内心脏骤停后最初追求但后来撤回治疗的人。有决策冲突的代理人描述了支持不足、医学理解差以及对患者治疗偏好缺乏明确性。
这些发现深入了解了失去亲人的 ICU 代理人的经验。总体调查评分较低可能反映了回顾性测量。追求治疗的代理人代表性不足。需要为失去亲人的代理人提供新的支持方法。
