Melltorp G, Nilstun T
Department of Anaesthesiology, Central Hospital, Växjö, Sweden.
Intensive Care Med. 1996 Oct;22(10):1015-9. doi: 10.1007/BF01699221.
To study the current practice of documenting decisions to forego life-sustaining treatment in an intensive care unit (ICU), using the Swedish Medical Records Act as a frame of reference.
The ICU at Malmoe General Hospital, Sweden.
The medical records of the first 600 cases treated in the ICU in 1992.
Analysis of documents and informal observational procedures.
Decisions to forego life-sustaining treatment were documented in the medical records of 34 patients, 17 of whom died in the ICU. In many cases, the treatment is specified, but often it is only rather vaguely described. The main reason for foregoing treatment is poor prognosis. There is no indication that the decisions had been discussed with the patients. In 18 of the 34 medical records, there are notes indicating that relatives were informed about the decision. Notes in most of the 34 medical records imply that joint deliberation took place between the anaesthesiologists in the ICU and the other physician(s) responsible for the treatment of the patient.
The medical records give a fairly accurate picture of the frequency with which such decisions are made at this particular ICU, although the number might be somewhat underestimated. However, the content of the documentation is rather scanty and does not fully satisfy the requirements of the Swedish Medical Records Act. Further studies are needed to warrant any generalization.
以瑞典医疗记录法为参照标准，研究重症监护病房（ICU）中记录放弃生命维持治疗决策的当前做法。
瑞典马尔默综合医院的ICU。
1992年在该ICU接受治疗的前600例病例的医疗记录。
对文件进行分析并采用非正式观察程序。
34例患者的医疗记录中有放弃生命维持治疗的决策记录，其中17例在ICU死亡。在许多情况下，治疗措施有明确规定，但通常描述得相当模糊。放弃治疗的主要原因是预后不良。没有迹象表明这些决策已与患者进行过讨论。在34份医疗记录中的18份里，有记录表明已将决策告知亲属。34份医疗记录中的大多数记录暗示，ICU的麻醉医生与负责该患者治疗的其他医生进行了共同商讨。
医疗记录对该特定ICU做出此类决策的频率给出了较为准确的描述，尽管实际数量可能略有低估。然而，记录内容相当简略，不完全符合瑞典医疗记录法的要求。需要进一步研究以确保能进行任何概括总结。
