Life-sustaining treatment preferences: matches and mismatches between patients' preferences and clinicians' perceptions.
Life-sustaining treatment preferences: matches and mismatches between patients' preferences and clinicians' perceptions.
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DOI：
10.1016/j.jpainsymman.2012.07.002
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发表时间：
2013-07
影响因子：
4.7
通讯作者：
Engelberg, Ruth A.
中科院分区：
文献类型：
--
作者：
Downey, Lois;Au, David H.;Curtis, J. Randall;Engelberg, Ruth A.
关键词：
临床医生更好地了解患者的临终治疗偏好，有可能减少不必要的治疗，降低医疗保健成本，并改善临终护理。调查患者对维持生命治疗的偏好、临床医生理解这些偏好的准确性以及患者偏好和临床医生错误的预测因素。对196名参与随机试验的慢性阻塞性肺疾病（COPD）男性退伍军人的观察性研究。测量包括患者在当前健康状况下对机械通气（MV）和心肺复苏（CPR）的偏好，以及门诊医生对这些偏好的信念。分析基于试验中54%的参与者，他们拥有完整的患者/临床医生治疗偏好数据。患者更容易接受CPR而不是MV（76% vs.61%; P<0.001）。对两种治疗的偏好与患者在生命的最后一周内避免生命维持治疗的重要性显著相关（MV：B=-0.11，P<0.001; CPR：B=-0.09，P=0.001）。当反应被二分时（愿意/不愿意接受治疗），医生的看法在75%的CPR病例和61%的MV病例中与患者的偏好相匹配。当患者倾向于不太积极的治疗时，医生的错误会增加（MV：B=-0.28，P<0.001; CPR：B=-0.32，P<0.001）。当患者不想接受治疗时，临床医生更容易在患者的意愿上犯错误。基于临床医生的看法做出的治疗决定可能导致昂贵和不必要的治疗。临终关怀可以受益于增加临床医生与患者关于临终关怀的讨论，特别是如果讨论包括患者关于治疗风险的教育，并允许临床医生形成和保持对患者偏好的准确印象。
Better clinician understanding of patients’ end-of-life-treatment preferences has the potential for reducing unwanted treatment, decreasing health care costs, and improving end-of-life care. To investigate patient preferences for life-sustaining therapies, clinicians’ accuracy in understanding those preferences, and predictors of patient preference and clinician error. Observational study of 196 male veterans with chronic obstructive pulmonary disease (COPD) who participated in a randomized trial. Measures included patients’ preferences for mechanical ventilation (MV) and cardiopulmonary resuscitation (CPR) if needed in their current state of health, and outpatient clinicians’ beliefs about those preferences. Analyses were based on 54% of participants in the trial who had complete patient/clinician data on treatment preferences. Patients were more receptive to CPR than MV (76% vs. 61%; P<0.001). Preferences for both treatments were significantly associated with the importance patients assigned to avoiding life-sustaining therapies during the final week of life (MV: b=−0.11, P<0.001; CPR: b=−0.09, P=0.001). When responses were dichotomized (would/wouldn’t want treatment), physicians’ perceptions matched patient preferences in 75% of CPR cases and 61% of MV cases. Physician errors increased as patients preferred less aggressive treatment (MV: b=−0.28, P<0.001; CPR: b=−0.32, P<0.001). Clinicians erred more often about patients’ wishes when patients did not want treatment than when they wanted it. Treatment decisions based on clinicians’ perceptions could result in costly and unwanted treatments. End-of-life care could benefit from increased clinician-patient discussion about end-of-life care, particularly if discussions included patient education about risks of treatment and allowed clinicians to form and maintain accurate impressions of patients’ preferences.
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影响因子：
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作者：
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DOI：
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