Elstein A S, Christensen C, Cottrell J J, Polson A, Ng M
Department of Medical Education, University of Illinois at Chicago, 60612-7309, USA.
Crit Care Med. 1999 Jan;27(1):58-65. doi: 10.1097/00003246-199901000-00027.
To assess the effects of prognostic estimates, perceived benefit of treatment, and practice style on decision-making in critical care.
Randomized assignment of subjects to either of two versions of a questionnaire designed to elicit treatment decisions for six intensive care unit cases based on actual patients. One version offered optimistic survival forecasts; the other, pessimistic forecasts.
A random sample of 120 clinicians obtained from the Canadian Critical Care Society was contacted by mail. One version of the questionnaire was randomly assigned and mailed to each. Thirty-four replies, 17 for each version (response rate, 28%), were received and analyzed.
A list of treatment/management options was developed for each case, in three categories: recommended, questionable, and unacceptable. Subjects were also able to list new options that they would order that were not on the list. The dependent variables were the number of actions ordered in each category and the total for each case. Perceived benefit was measured by comparing subjective estimates of the probability of survival with the optimistic/pessimistic forecast given in the case. Practice style was assessed by correlating the total number of actions ordered across all possible pairs of cases. There were no significant differences between the two questionnaires on actions ordered either by category or by amount per category. Perceived benefit did not appear to be an important factor in decision-making. However, statistically significant correlations provide evidence for practice style in intensive care unit decision-making on an interventionist/noninterventionist dimension.
There is no evidence that erroneous or biased prognostic estimates affect intensive care unit treatment choices. Neither the principle of maximizing expected utility nor the Rule of Rescue appear to affect these decisions systematically, but practice style does.
评估预后估计、治疗的感知益处及医疗方式对重症监护决策的影响。
将受试者随机分配至两种版本的问卷之一，该问卷旨在根据实际患者情况引出针对六个重症监护病房病例的治疗决策。一个版本提供乐观的生存预测；另一个版本提供悲观的预测。
通过邮件联系从加拿大重症监护学会获得的120名临床医生的随机样本。问卷的一个版本被随机分配并邮寄给每个人。共收到34份回复，每个版本各17份（回复率为28%），并进行了分析。
为每个病例制定了一份治疗/管理选项清单，分为三类：推荐、有疑问和不可接受。受试者还能够列出他们会选择的清单上未有的新选项。因变量是每个类别中所选择措施的数量以及每个病例的总数。通过将主观估计的生存概率与病例中给出的乐观/悲观预测进行比较来衡量感知益处。通过对所有可能的病例对中所选择措施的总数进行相关性分析来评估医疗方式。在按类别或按每个类别的数量所选择的措施方面，两份问卷之间没有显著差异。感知益处似乎不是决策中的一个重要因素。然而，具有统计学意义的相关性为重症监护病房在干预主义/非干预主义维度上的决策中的医疗方式提供了证据。
没有证据表明错误或有偏差的预后估计会影响重症监护病房的治疗选择。最大化预期效用原则和救援法则似乎都没有系统地影响这些决策，但医疗方式有影响。
