"It blew my mind": exploring the difficulties of anesthesia informed consent through narrative.
"It blew my mind": exploring the difficulties of anesthesia informed consent through narrative.
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“这让我大吃一惊”：通过叙述探索麻醉知情同意的困难。
DOI：
10.1097/aln.0b013e318197ff99
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发表时间：
2009
期刊：
影响因子：
8.8
通讯作者：
A. Shafer
中科院分区：
文献类型：
--
作者：
A. Shafer
通过叙述探索麻醉知情同意的困难这篇文章由Waisel等人在这一期的麻醉学中充满了令人信服的叙述，并唤起了我们自己的经验和其他故事。在一个这样的故事中，由Maren Grainger-Monsen拍摄的关于一位患有晚期胃癌的阿富汗老人的纪录片《屏住呼吸》记录了一个知情同意的误解导致了一个令人心碎的时刻。高知先生在与他富有同情心的、技术高超的肿瘤学家的多次诊所访问中被拍摄下来。在每次访问中，我们通过翻译“听到”病人拒绝化疗。但直到影片深入时，我们才得知病人误解了他的治疗方案。他拒绝了化疗，因为化疗是以持续输液的方式提供的，这种方法会干扰他的宗教要求，即每天祈祷五次要“干净”。直到他的一个女儿，活泼的，完全双语的，参加了一次办公室访问，所有人都清楚，他会同意任何其他形式的化疗。这是一个在屏幕上释放愤怒、沮丧和困惑的时刻。与此同时，我们内心也感受到了共情关怀的痛苦--这种痛苦提醒我们，在这个被称为医学的努力中，我们都是人类。麻醉学，在很多方面，都是医疗护理的结晶。我们很少，如果有的话，有奢侈的多次办公室访问与病人和家人联系。因此，如果知情同意的困难发生在重复的，相对较长的访问，有多少磨难必须出现在时间紧迫的竞技场，病人会见麻醉师，必须信任（在某种程度上）这个陌生人与他或她的生命？因此，Waisel等人的文章确实很受欢迎。因为这项研究不仅让我们在阅读叙述时意识到了人与人之间的遭遇，而且还让我们认识到，即使没有血氧饱和度下降或ST段上升，麻醉学的实践也会有压力。在这项研究中，叙述是从居民和其他学员计划参加专门为麻醉师设计的关系和沟通技巧的教育计划。给受训者以下写作提示：“写一个你觉得特别具有挑战性的患者/家庭的知情同意经历。”这是值得注意的几个原因。首先，培训计划中的时间用于提高一套技能，其中不包括气道管理，药物给药，区域针头放置或监测技术。尽管早期的编辑评论贬低了麻醉模拟器用于相关技能发展的价值，但这些技能、态度和知识的认可和推广部分源于参与基于模拟的麻醉培训的人员的研究和教育努力。经常被称为非技术技能，团队合作，领导能力和沟通技巧是嵌入和讨论模拟器培训和汇报。在手术室或重症监护室的高度动态环境中，人际交往技能是良好患者护理的核心。第二，要求麻醉实习生书写。写作给了居民和研究员在自己的培训发言权。在被要求写作并将这些作品作为教育课程的案例时，教师们甚至在任何课程开始之前就已经在向学习者教授和传达关键信息：你要说的话是有价值的;你要说的话是你独有的，但也是别人感兴趣的;你要说的话不能用多项选择题的分数来捕捉;而且，也许最重要的是，我们所做的许多事情都没有一个唯一的正确答案。人与人之间的互动是复杂的，多层次的，往往模棱两可，有时令人沮丧。叙事医学是从文学和医学的医学人文领域发展起来的一门学科，它探讨了仔细分析文本和医生之间的关系。医生和实习医生使用写作可以被视为一种促进反思的工具;在课堂或其他团体的环境中，它促进了社区，更深层次的自我呈现，承认脆弱性，易犯错误，以及其他经常被医学完美期望的压力所压制的人类特征。第三，这项研究承认了医学伦理的广泛、包容性定义。而不是在道德术语和系统的瘴气中迷失和昏迷（自治！道德伦理！你好！deontol此编辑视图伴随以下文章：Waisel DB，Lamiani G，Sandrock NJ，Pascucci R，Truog RD，Meyer EC：麻醉学学员在获得知情同意时面临伦理，实践和关系挑战。麻醉学2009; 110：480-6。
Exploring the Difficulties of Anesthesia Informed Consent through Narrative THE article by Waisel et al. in this issue of ANESTHESIOLOGY is packed with compelling narratives and evokes both our own experiences and other tales. In one such tale, chronicled in Hold Your Breath—a documentary film by Maren Grainger-Monsen about an elderly Afghani man with advanced stomach cancer—an informed consent misunderstanding results in a heart-rending moment.* Mr. Kochi is filmed during multiple clinic visits with his compassionate, highly skilled oncologist. At each visit we “hear,” through an interpreter, the patient refuse chemotherapy. But it is not until well into the film that we learn the patient misunderstood his treatment options. He had refused chemotherapy because it was offered as a continuous infusion, a method which would interfere with his religious requirements to be “clean” five times a day for prayer. Not until one of his daughters, feisty and completely bilingual, attends an office visit, does it becomes clear to all that he would have consented to any other form of chemotherapy. It is a moment which elicits anger, frustration, and bewilderment on screen. Within, meanwhile, we feel the pang of empathic concern – the pang that reminds us that we are all human in this endeavor called medicine. Anesthesiology, in so many ways, is crystallized medical care. We rarely, if ever, have the luxury of multiple office visits to connect with the patient and family. Hence, if informed consent difficulties occur in the setting of repeated, relatively lengthy visits, how many tribulations must arise in the time-crunch arena where the patient meets an anesthesiologist and must trust (to some degree) this stranger with his or her life? Thus the article by Waisel et al. is welcome indeed. For not only does the study offer us the pangs of acknowledgment of human-human encounters as we read the narratives, but it also brings to the fore the fact that the practice of anesthesiology can be stressful–even without a drop in oxygen saturation or rise in ST segments. In the study, narratives were generated from resident and fellow trainees scheduled to attend an education program on relational and communication skills specifically designed for the anesthesiologist. Trainees were given the following writing prompt: “Write about an informed consent experience with a patient/family that you found particularly challenging.” This is remarkable for several reasons. First, time in the training program was devoted to enhancing a skill set which does not include airway management, drug dosing, regional needle placement, or monitoring technique. Despite early editorial commentary which devalued the use of anesthesia simulators for relational skill development, the recognition and promotion of such skills, attitudes, and knowledge stem in part from the research and educational efforts of those involved in simulation-based anesthesia training. Frequently termed nontechnical skills, teamwork, leadership, and communication skills are embedded and discussed in simulator training and debriefing. In the highly dynamic setting of an operating suite or intensive care unit bay, interpersonal skills are central to good patient care. Second, anesthesia trainees were asked to write. The writing gave residents and fellows a voice in their own training. In being asked to write and using the writings as cases for educational sessions, the teachers were already teaching and conveying key messages to the learners even before any of the sessions began: what you have to say is valuable; what you have to say is unique to you but of interest to others; what you have to say cannot be captured by markings on a multiple choice test; and, perhaps most importantly, there is no single right answer for much of what we do. Interactions between people are complex, multilayered, often ambiguous, and sometimes frustrating. Narrative medicine emerged from the medical humanities field of literature and medicine as an academic discipline that explores the relationships between careful analysis of text and doctoring. The use of writing by doctors and doctors-in-training can be viewed as a tool which promotes reflection; in the setting of a classroom or other group, it promotes community, a deeper presentation of self, and an acknowledgment of vulnerability, fallibility, and other human traits frequently squelched by the press of expectations for perfection in medicine. Third, the study acknowledges a wide, inclusive definition of medical ethics. Rather than left to wander lost and stuporous in a miasma of ethics terminology and systems (autonomy! virtue-ethics! casuistry! deontolThis Editorial View accompanies the following article: Waisel DB, Lamiani G, Sandrock NJ, Pascucci R, Truog RD, Meyer EC: Anesthesiology trainees face ethical, practical, and relational challenges in obtaining informed consent. ANESTHESIOLOGY 2009; 110:480–6.