O'Callahan J G, Fink C, Pitts L H, Luce J M
Department of Medicine, School of Medicine, University of California, San Francisco, USA.
Crit Care Med. 1995 Sep;23(9):1567-75. doi: 10.1097/00003246-199509000-00018.
To characterize the withholding or withdrawing of life support from patients with severe head injury.
San Francisco General Hospital, a city and county hospital with a Level I trauma center.
A standardized questionnaire was used to collect data on demographics and functional outcome of severely head-injured (Glasgow Coma Score of < or = 7) patients admitted to the medical-surgical intensive care unit, and to interview the patients' physician and family members.
Forty-seven patients who were admitted to a medical-surgical intensive care unit over a 1-yr period.
Twenty-four patients had life support withheld or withdrawn, and 23 patients did not.
Physician and family separately assessed patient's probable functional outcome, degree of communication between them, reasons important in recommending or deciding on discontinuation of life support, and the result of action taken. Six months later, the families reviewed the process of their decision, how well physician(s) had communicated, and what might have improved communication. Of 24 patients with life support discontinued, 22 died; two were discharged from the hospital. Twenty-three of the 24 patients had a poor prognosis on admission. Of the 23 patients who were continued on life support for the duration of their hospitalization, ten had a poor (p < .001) prognosis on admission. Prognosis improved for two patients from the first group and five from the latter. Family's assessment of prognosis agreed with physician's assessment in 22 of the 24 patients from whom life support was discontinued (p < .001). Physicians' ability to convey the prognosis appeared to influence families' assessments. Physicians' considerations in recommending limitation of care and families' considerations in making decisions were the same, primarily an inevitably poor prognosis. Neither physician nor families cited cost or availability of care as a deciding factor. Two families disagreed with the recommendation to limit care after initial agreement because the patients' prognosis improved from "likely death" to "vegetative." Care was therefore continued, and both patients remained vegetative 6 months after admission to the hospital and discharge to chronic care facilities.
Life support is commonly withheld or withdrawn from patients with severe head injury at San Francisco General Hospital, and usually it is accompanied by death. A reciprocal consideration exists in most cases between the physician and family making the difficult decision to limit care. Care is provided for patients whose families request it despite physician recommendations.
描述对重度颅脑损伤患者停止或撤除生命支持的情况。
旧金山总医院，一家设有一级创伤中心的市县医院。
采用标准化问卷收集入住内科 - 外科重症监护病房的重度颅脑损伤（格拉斯哥昏迷评分≤7分）患者的人口统计学和功能转归数据，并对患者的医生和家属进行访谈。
1年内入住内科 - 外科重症监护病房的47例患者。
24例患者的生命支持被停止或撤除，23例患者未停止。
医生和家属分别评估患者可能的功能转归、他们之间的沟通程度、在建议或决定停止生命支持方面重要的原因以及所采取行动的结果。6个月后，家属回顾他们的决策过程、医生沟通的效果以及哪些方面可能改善沟通。在24例生命支持被停止的患者中，22例死亡；2例出院。24例患者中有23例入院时预后不良。在23例住院期间持续接受生命支持的患者中，10例入院时预后不良（p <.001）。第一组中有2例患者和第二组中有5例患者的预后有所改善。在24例生命支持被停止的患者中，22例患者家属对预后的评估与医生的评估一致（p <.001）。医生传达预后的能力似乎影响家属的评估。医生在建议限制治疗时的考虑因素与家属在做决策时的考虑因素相同，主要是预后必然不良。医生和家属均未将费用或医疗可及性作为决定因素。两个家庭在最初同意后不同意限制治疗的建议，因为患者的预后从“可能死亡”改善为“植物人状态”。因此继续进行治疗，两名患者在入院6个月后出院并转至长期护理机构时仍处于植物人状态。
在旧金山总医院，重度颅脑损伤患者通常会被停止或撤除生命支持，且通常随之而来的是死亡。在做出限制治疗这一艰难决策时，医生和家属在大多数情况下会相互考虑。对于家属不顾医生建议仍要求治疗的患者，会继续提供治疗。
