Markson L, Clark J, Glantz L, Lamberton V, Kern D, Stollerman G
Center for Health Quality, Outcomes, and Economic Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA 01730, USA.
J Am Geriatr Soc. 1997 Apr;45(4):399-406. doi: 10.1111/j.1532-5415.1997.tb05162.x.
Although previous studies have shown physicians support advance directives, little is known about how they actually participate in decision-making. This study investigate (1) how much experience physicians have had discussing and following advance preferences and (2) how physicians perceive their role in the advance decision-making process.
Mail survey conducted in 1993.
The Department of Veterans Affairs.
A national probability sample of 1050 VA internists, family physicians, and generalists.
Questionnaires were returned by 67% of participants. In the last year, 79% stated they had discussed advance preference with at least one patient, and 19% had talked to more than 25. Seventy-three percent had used a written directive to make decisions for at least one incompetent patient. Younger age, board certification, spending less time in the outpatient setting, and personal experience with advance decision-making, were all associated independently with having advance preference discussions. Among physicians who had discussions, 59% said they often initiated the discussion, 55% said discussions often occurred in inpatient settings, and 31% said discussions often occurred in outpatient settings. Eighty-two percent of those responding thought physicians should be responsible for initiating discussions. Most would try to persuade a patient to change a decision that was not well informed (91%), not medically reasonable (88%), or not in the patient's best interest (88%); few would attempt to change decisions that conflicted with their own moral beliefs (14%).
Physicians report that they are actively involved with their patients in making decisions about end-of-life care. Most say they have had recent discussions with at least some of their patients and feel that as physicians they should play a large and important role in soliciting and shaping patient preferences.
尽管先前的研究表明医生支持预先指示，但对于他们实际如何参与决策却知之甚少。本研究调查了：（1）医生在讨论和遵循预先偏好方面有多少经验；（2）医生如何看待自己在预先决策过程中的角色。
1993年进行的邮寄调查。
退伍军人事务部。
1050名退伍军人事务部内科医生、家庭医生和全科医生的全国概率样本。
67%的参与者回复了问卷。在过去一年中，79%的人表示他们至少与一名患者讨论过预先偏好，19%的人与超过25名患者讨论过。73%的人曾使用书面指示为至少一名无行为能力的患者做决策。年龄较小、拥有委员会认证、在门诊环境中花费时间较少以及有预先决策的个人经历，都与进行预先偏好讨论独立相关。在进行过讨论的医生中，59%的人表示他们经常发起讨论，55%的人表示讨论经常在住院环境中进行，31%的人表示讨论经常在门诊环境中进行。82%的受访者认为医生应该负责发起讨论。大多数人会试图说服患者改变未充分知情（91%）、不符合医学常理（88%）或不符合患者最佳利益（88%）的决定；很少有人会试图改变与自己道德信念相冲突的决定（14%）。
医生报告称他们积极参与与患者就临终护理决策的过程。大多数人表示他们最近至少与一些患者进行过讨论，并认为作为医生，他们在征求和塑造患者偏好方面应发挥重要且关键的作用。
