Surgeons, intensivists, and the covenant of care: Administrative models and values affecting care at the end of life - Updated
Surgeons, intensivists, and the covenant of care: Administrative models and values affecting care at the end of life - Updated
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DOI：
10.1097/00003246-200305000-00039
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发表时间：
2003-05-01
影响因子：
8.8
通讯作者：
Stewart, RM
中科院分区：
文献类型：
--
作者：
Cassell, J;Buchman, TG;Stewart, RM
背景：临终关怀在重症监护病房中仍然是一项具有挑战性和复杂性的活动。关于临终关怀的管理模式对临终关怀的影响的信息很少。目的：比较和对比使用“半封闭式”、“开放式”和“封闭式”管理模式的重症监护病房的临终关怀服务。设计：对三个重症监护病房进行人种学研究。研究背景：美国和新西兰的大学医院。研究对象：大约600名医生、护士、专职卫生人员、患者、家属和朋友。测量和主要结果；民族志观察分别在三个地点进行了75、3和10周。观察了80次临终关怀事件。护理人员和家庭之间的互动根据管理模式的不同而不同，这取决于外科医生或重症监护医生是否对患者负有主要责任。这导致了从“治愈”到“舒适”的不同时间，以及家庭不同的决策权。结论：临终关怀根据管理模式的不同而不同。当外科医生对病人负有主要责任时，最重要的目标是战胜死亡。当加强治疗师完全负责患者时，稀缺的资源被考虑在内，生活质量是一个重要的变量。关于改善重症监护病房临终决定执行方式的讨论很少考虑影响此类决定的管理模式和个人、专业和国家价值观。为了改善临终关怀，我们必须批判性地检查这些特征。
Context: End-of-life care remains a challenging and complex activity in critical care units. There is little information concerning the influence of administrative models of care delivery on end-of-life care.Objective: To compare and contrast end-of-life care delivery in intensive care units using "semiclosed," "open," and "closed" administrative models.Design: Ethnographic study of three critical care units.Setting: University hospitals in the United States and New Zealand.Subjects: Approximately 600 physicians, nurses, allied health personnel, patients, family members, and friends.Measurements and Main Results; Ethnographic observations were made at three sites for 75, 3, and 10 wks, respectively. Eighty end-of-life care episodes were observed. The interactions among care personnel and families varied according to the administrative model, depending on whether surgeons or intensivists had primary patient responsibility. This led to differential timing on the shift from "cure" to "comfort," and differential decision-making power for families.Conclusions: End-of-life care varies according to the administrative model. When surgeons have primary responsibility for the patient, the most important goal is defeating death. When intensivists have sole patient responsibility, scarce resources are considered and quality of life is a significant variable. Discussions about improving the way end-of-life decisions are carried out in intensive care units rarely consider the administrative models and personal, professional, and national values affecting such decisions. To improve care at the end of life, we must critically examine these features.