在讨论预立医疗指示后患者的知识及医生对治疗偏好的预测。
Patient knowledge and physician predictions of treatment preferences after discussion of advance directives.
作者信息
Fischer G S, Tulsky J A, Rose M R, Siminoff L A, Arnold R M
机构信息
Section of Palliative Care and Medical Ethics, Center for Medical Ethics, University of Pittsburgh School of Medicine, PA 15213, USA.
出版信息
J Gen Intern Med. 1998 Jul;13(7):447-54. doi: 10.1046/j.1525-1497.1998.00133.x.
OBJECTIVE
To determine patient knowledge about life-sustaining treatments and physician understanding of patient preferences for proxies and treatments after outpatient discussions about advance directives.
DESIGN
Cross-sectional interview-based and questionnaire-based survey.
SETTING
Two university general internal medicine practices, two Department of Veterans Affairs general internal medicine practices, and one university-based geriatrics practice, in two different cities.
PATIENTS
Fifty-six patients of primary care internists.
INTERVENTION
Physicians discussed "advance directives" (ADs) with one randomly selected patient during an outpatient visit.
MEASUREMENTS AND MAIN RESULTS
After the discussions, physicians identified the patient's proxy and predicted the patient's preferences for treatment in 20 scenarios. Patients provided treatment preferences in the 20 scenarios, the name of their preferred surrogate decision maker, and their understanding of cardiopulmonary resuscitation and mechanical ventilation. Of the 39 patients who discussed resuscitation, 43% were able to identify two important characteristics; 26% identified none; 66% did not know that most patients need mechanical ventilation after undergoing resuscitation. None of the 43 patients who had a discussion about mechanical ventilation had a good understanding of it; 67% did not know that patients generally cannot talk while on ventilators; 46% expressed serious misconceptions about ventilators. There was poor agreement between physicians and their patients regarding treatment preferences in 18 of 20 scenarios (kappa -0.04 to 0.31). Physicians correctly identified the proxy 89% of the time (kappa 0.78).
CONCLUSIONS
Patients leave routine AD discussions with serious misconceptions about life-sustaining treatments. Physicians are unable to predict treatment preferences but do learn about patients' preferences for surrogate decision makers.
目的
确定患者对维持生命治疗的了解程度，以及医生在门诊讨论预立医疗指示后，对患者关于代理人及治疗偏好的理解。
设计
基于访谈和问卷的横断面调查。
地点
位于两个不同城市的两家大学普通内科诊所、两家退伍军人事务部普通内科诊所，以及一家大学老年病诊所。
患者
56名初级保健内科医生的患者。
干预措施
医生在门诊就诊期间与一名随机挑选的患者讨论“预立医疗指示”（ADs）。
测量指标及主要结果
讨论后，医生确定患者的代理人，并预测患者在20种情况下对治疗的偏好。患者提供了20种情况下的治疗偏好、他们首选的替代决策者的姓名，以及他们对心肺复苏和机械通气的理解。在39名讨论过复苏的患者中，43%能够识别两个重要特征；26%一个也没识别出来；66%不知道大多数患者在接受复苏后需要机械通气。在43名讨论过机械通气的患者中，没有人对其有很好的理解；67%不知道患者在使用呼吸机时通常无法说话；46%对呼吸机表达了严重的误解。在20种情况中的18种情况下，医生和患者在治疗偏好上的一致性较差（kappa值为-0.04至0.31）。医生正确识别代理人的比例为89%（kappa值为0.78）。
结论
患者在常规的预立医疗指示讨论后，对维持生命治疗存在严重误解。医生无法预测治疗偏好，但确实了解了患者对替代决策者的偏好。
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