Hospital-Based Physicians' Intubation Decisions and Associated Mental Models when Managing a Critically and Terminally Ill Older Patient.
Hospital-Based Physicians' Intubation Decisions and Associated Mental Models when Managing a Critically and Terminally Ill Older Patient.
复制标题
DOI：
10.1177/0272989x17738958
复制
发表时间：
2018-04
期刊：
影响因子：
--
通讯作者：
Barnato AE
中科院分区：
文献类型：
--
作者：
Haliko S;Downs J;Mohan D;Arnold R;Barnato AE
临终时急性护理治疗强度的变化更受医院和提供者特征的影响，而不是患者的偏好。我们试图描述医生在遇到模拟的危重和绝症老人时的心理模型(即思维过程)，并根据他们的治疗计划是符合患者偏好还是偏好不一致来比较这些模型。来自三个学术医疗中心的73名医院医生进行了一次模拟的患者相遇，并在观看他们相遇的视频时完成了心理模型采访。我们使用了一种“专家”模式来编写采访代码。然后，我们使用Kruskal Wallis测试来比较提供偏好一致治疗的医生和提供偏好不一致治疗的医生的加权心理模型主题。66名医生(90%)提供了偏好一致的治疗，7名(10%)医生提供了偏好不一致的治疗(即给患者插管)。给患者插管的医生更有可能强调患者情况的可逆性和紧急性质(z=−2.111，p=.035)，他们自己的舒适度(z=−2.764，p=.006)，而很少关注明确的患者偏好(z=2.380，p=.017)。在音频/视频提示的情况下进行后决策面试可能会导致事后认识偏差。专家模型尚未得到验证，也可能不是详尽的。小样本量限制了泛化能力和能力。提供偏好不一致的医院医生使用不同的心理模型来为危重和绝症模拟病例做出决策。这些差异可能为未来的干预提供目标，以促进对重病患者的偏好一致性护理。
Variation in the intensity of acute care treatment at the end-of-life is influenced more strongly by hospital and provider characteristics than patient preferences. We sought to describe physicians’ mental models (i.e., thought processes) when encountering a simulated critically and terminally ill elder and to compare those models based on whether their treatment plan was patient preference-concordant or preference-discordant. 73 hospital-based physicians from three academic medical centers engaged in a simulated patient encounter and completed a mental model interview while watching the video recording of their encounter. We used an “expert” model to code the interviews. We then used Kruskal Wallis tests to compare the weighted mental model themes of physicians who provided preference-concordant treatment versus with those who provided preference-discordant treatment. 66 (90%) physicians provided preference-concordant treatment and 7 (10%) provided preference-discordant treatment (i.e., they intubated the patient). Physicians who intubated the patient were more likely to emphasize the reversible and emergent nature of the patient situation (z=−2.111, p=.035), their own comfort (z=−2.764, p=.006), and rarely focused on explicit patient preferences (z=2.380, p=.017). Post decisional interviewing with audio/video prompting may induce hindsight bias. The expert model has not yet been validated and may not be exhaustive. The small sample size limits generalizability and power. Hospital-based physicians providing preference-discordant used a different mental model for decision making for a critically and terminally ill simulated case. These differences may offer targets for future interventions to promote preference-concordant care for seriously ill patients.