Physicians' decision-making roles for an acutely unstable critically and terminally ill patient.
Physicians' decision-making roles for an acutely unstable critically and terminally ill patient.
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DOI：
10.1097/ccm.0b013e318287f0dd
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发表时间：
2013-06
影响因子：
8.8
通讯作者：
Barnato AE
中科院分区：
文献类型：
--
作者：
Uy J;White DB;Mohan D;Arnold RM;Barnato AE
临终患者对生命维持技术的使用存在很大差异，但我们对医生最初入住 ICU 和插管决策过程的差异知之甚少。描述医院医生沟通行为的变化以及对于急性不稳定的危重和末期患者的 ICU 入院和插管决策的决策作用。我们对医生决策的多中心观察研究的转录模拟遭遇进行了二次分析。该模拟描绘了一名 78 岁的男性，患有转移性胃癌，缺氧危及生命。他对入住 ICU 和插管有稳定的潜在偏好，如果被问到，他或他的妻子会报告。我们对沟通行为（提供医疗信息、引发偏好/价值观、让患者/代理人参与审议以及提供治疗建议）进行编码，并使用先前开发的框架将受试者医生分为四种相互排斥的决策角色：信息型（仅提供医疗信息）、促进型（信息+引发偏好/价值观+指导代理人应用偏好/价值观）、协作型（信息+引发+指导+提出建议）和指示（做出独立的治疗决定）。来自 3 个美国学术医疗中心的 24 名急诊医生、37 名住院医生和 37 名重症医生。受试者医师从医学院毕业后平均工作时间为 12.4 (SD 9.0) 年。 38/98（39%）的医生将患者送往 ICU，9/98（9%）的医生最终决定插管。大多数（93/98（95%））至少提供了一些医疗信息，但很少有人解释插管（26/98（27%））或不插管（37/98（38%））的短期预后。许多（80/98（82%））引出患者的插管偏好，但很少（35/98（36%））探索患者更广泛的价值观。根据编码行为，我们将 1/98 (1%) 归类为信息性行为，48/98 (49%) 归类为促进性行为，36/98 (37%) 归类为协作性行为，12/98 (12%) 归类为指导性行为； 1/98 (1%) 无法归入类别。没有观察到的医生特征可以预测决策作用。大多数医生发挥了促进或协作作用，尽管在这种时间紧迫的情况下，与无时间压力的 ICU 家庭会议中记录的情况相比，更大比例的医生承担了指导作用，这表明医生的角色可能取决于具体情况。
There is substantial variation in use of life sustaining technologies in patients near the end of life but little is known about variation in physicians’ initial ICU admission and intubation decision making processes. To describe variation in hospital-based physicians’ communication behaviors and decision making roles for ICU admission and intubation decisions for an acutely unstable critically and terminally ill patient. We conducted a secondary analysis of transcribed simulation encounters from a multi-center observational study of physician decision making. The simulation depicted a 78 year-old man with metastatic gastric cancer and life threatening hypoxia. He has stable underlying preferences against ICU admission and intubation that he or his wife will report if asked. We coded encounters for communication behaviors (providing medical information, eliciting preferences/values, engaging the patient/surrogate in deliberation, and providing treatment recommendations) and used a previously-developed framework to classify subject physicians into four mutually-exclusive decision-making roles: informative (providing medical information only), facilitative (information + eliciting preferences/values + guiding surrogate to apply preferences/values), collaborative (information + eliciting + guiding + making a recommendation) and directive (making an independent treatment decision). 24 emergency physicians, 37 hospitalists, and 37 intensivists from 3 US academic medical centers. Subject physicians average 12.4 (SD 9.0) years since graduation from medical school. 38/98(39%) physicians sent the patient to the ICU, and 9/98(9%) ultimately decided to intubate. Most (93/98 (95%)) provided at least some medical information, but few explained the short-term prognosis with (26/98 (27%)) or without intubation (37/98 (38%)). Many (80/98 (82%)) elicited the patient's intubation preferences, but few (35/98 (36%)) explored the patient's broader values. Based on coded behaviors, we categorized 1/98 (1%) as informative, 48/98 (49%) as facilitative, 36/98 (37%) as collaborative, and 12/98 (12%) as directive; 1/98 (1%) could not be placed into a category. No observed physician characteristics predicted decision making role. The majority of the physicians played a facilitative or collaborative role, although a greater proportion assumed a directive role in this time-pressured scenario than has been documented in non-time pressured ICU family meetings, suggesting that physicians’ roles may be context-dependent.