Advance directives: can patients' stated treatment choices be used to infer unstated choices?
Advance directives: can patients' stated treatment choices be used to infer unstated choices?
复制标题
预先指示：患者陈述的治疗选择是否可以用来推断未陈述的选择？
DOI：
10.1097/00005650-199402000-00001
复制
发表时间：
1994
期刊：
影响因子：
3
通讯作者：
Stoeckle,JD
中科院分区：
文献类型：
--
作者：
Emanuel,LL;Barry,MJ;Emanuel,EJ;Stoeckle,JD
预先指示作为一种将医疗干预措施与患者偏好相匹配的方法已得到广泛认可。然而，将预先指示应用于未指定的未来决策可能会出现问题。我们想知道预先指示中基于场景的治疗选择如何用于推断同一患者指定的其他选择。我们要求麻省总医院的 495 名门诊患者针对四种疾病情况分别陈述 11 种治疗选择。我们计算了似然比 (LR)，以了解一种选择对另一种选择的预测效果如何。在给定情况下的预测很强烈，并且遵循反映治疗侵入性的模式。因此，在同样的情况下，抗生素的减少预示着大手术的减少（LR 36.0-108.3）。对大手术的要求强烈预示着对抗生素的要求（LR 90.4-244.1）。要求进行大手术和减少抗生素使用是两个最具预测性的偏好；更传统地考虑的有关心肺复苏和机械通气的决策在 11 项干预措施中最具预测性的排名为第三至第九。情景之间的预测较弱，但仍然可能有用，并且遵循反映情景预测的模式。在最佳预后情况（有机会昏迷）中减少治疗可预测在其他情况下减少相同的治疗，LR 为 2.5-6.1。在最坏的预后情况（患有绝症的痴呆）中的治疗请求预测在其他情况下也有相同的请求，LR 为 5.2-30.5。这些数据表明，如果推论遵循对预后和治疗侵入性的考虑，那么患者基于场景的预先治疗选择可以提供潜在有用的信息，以应用于未指定的决策。为了获得最大的预测能力，治疗指令应使用一系列疾病场景，并包括抗生素使用和大手术等选择。
Advance directives have been widely endorsed as a method to match medical interventions to patients' preferences. However, applying advance directives to unspecified future decisions may be problematic. We wondered how well scenario-based treatment choices in advance directives can be used to infer other choices specified by the same patients. We asked 495 out-patients from the Massachusetts General Hospital to state 11 treatment choices in each of four illness scenarios. We calculated likelihood ratios (LRs) to see how well one choice could predict another. Predictions within a given scenario were strong and followed a pattern that reflected the invasiveness of the treatment. Thus, decline of antibiotics predicted decline of major surgery, in the same scenario (LR 36.0-108.3). Requests for major surgery strongly predicted requests for antibiotics (LR 90.4-244.1). Requests for major surgery and decline of antibiotics were the two most predictive preferences; more traditionally considered decisions about cardiopulmonary resuscitation and mechanical ventilation ranged from the third to ninth most predictive among the 11 interventions. Predictions between scenarios were weaker, but still potentially useful, and followed a pattern that reflected the prognoses of the scenarios. Declining treatment in the best prognosis scenario (coma-with-a-chance) predicted declining the same treatment in other scenarios with LRs of 2.5-6.1. Requests for treatment in the worst prognosis scenario (dementia-with-terminal-illness) predicted the same request in the other scenarios with LRs of 5.2-30.5. These data suggest that patients' advance scenario-based treatment choices can provide potentially useful information to apply to unspecified decisions if inferences follow considerations of prognosis and treatment invasiveness. For maximal predictive power, treatment directives should use a range of illness scenarios and include choices, among several others, on antibiotic use and major surgery.