Dowdy M D, Robertson C, Bander J A
Bon Secours St. Mary's Hospital, Richmond, VA, USA.
Crit Care Med. 1998 Feb;26(2):252-9. doi: 10.1097/00003246-199802000-00020.
To assess the effect of proactive ethics consultation on documented patient care communications and on decisions regarding high-risk intensive care unit (ICU) patients.
Prospective, controlled study.
Ninety-nine ICU patients treated with >96 hrs of continuous mechanical ventilation.
Three groups were compared: a) a baseline group enrolled in the study prior to the establishment of the hospital's ethics consultation service; b) a control group where ethics consultation was at the option of the care team; and c) a treatment group where the ethics service intervened proactively after patients received >96 hrs of continuous mechanical ventilation. Patient care planning, for subjects in the proactive group, was reviewed with physicians and with the care team using a standardized set of prompting questions designed to focus discussion of key decision-making and communication issues for critically and terminally ill patients. Issues and concerns were identified and action strategies were suggested to those in charge of the patient's care. Formal ethics consultation, using a patient care conference model, was made available upon request.
Post discharge chart reviews of the three groups indicated no statistically significant differences on important demographic variables including age, gender, and acuity. Comparisons of survivors and nonsurvivors for the three groups indicated, at statistically significant levels, more frequent and documented communications, more frequent decisions to forego life-sustaining treatment, and reduced length of stay in the ICU for the proactive consultation group.
Proactive ethics consultation for high-risk patient populations offers a promising approach to improving decision-making and communication and reducing length of ICU stay for dying patients.
评估前瞻性伦理咨询对已记录的患者护理沟通以及高危重症监护病房（ICU）患者决策的影响。
前瞻性对照研究。
99例接受持续机械通气超过96小时的ICU患者。
比较三组：a）在医院伦理咨询服务建立之前纳入研究的基线组；b）护理团队可选择进行伦理咨询的对照组；c）患者接受持续机械通气超过96小时后伦理服务进行前瞻性干预的治疗组。对于前瞻性组的患者，使用一套标准化的提示性问题与医生和护理团队一起审查患者护理计划，这些问题旨在聚焦对危重症和终末期患者关键决策和沟通问题的讨论。识别问题和关注点，并向负责患者护理的人员建议行动策略。根据要求可通过患者护理会议模式进行正式的伦理咨询。
对三组患者出院后的病历审查表明，在包括年龄、性别和病情严重程度在内的重要人口统计学变量上，三组之间无统计学显著差异。对三组患者中幸存者和非幸存者的比较表明，在统计学显著水平上，前瞻性咨询组的沟通更频繁且有记录，放弃维持生命治疗的决策更频繁，ICU住院时间缩短。
对高危患者群体进行前瞻性伦理咨询为改善决策和沟通以及缩短临终患者的ICU住院时间提供了一种有前景的方法。
