Clinical Momentum in the Intensive Care Unit A Latent Contributor to Unwanted Care
Clinical Momentum in the Intensive Care Unit A Latent Contributor to Unwanted Care
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DOI：
10.1513/annalsats.201611-931oi
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发表时间：
2017-03-01
影响因子：
8.3
通讯作者：
Schwarze, Margaret L.
中科院分区：
文献类型：
--
作者：
Kruser, Jacqueline M.;Cox, Christopher E.;Schwarze, Margaret L.
在美国，许多老年人在生命即将结束时接受侵入性医疗护理，通常在重症监护室（ICU）。然而，大多数老年人报告倾向于避免这种类型的医疗护理，并优先考虑舒适度和濒死生活质量。我们提出了一个新的术语，“临床势头”，描述了一个系统级的，潜在的，以前未被认识到的属性的临床护理，可能有助于提供不必要的护理在ICU。慢性危重病的例子说明了临床动力是如何产生和传播的长期疾病患者的护理。ICU是一个通常允许干预的环境，临床实践规范和常规护理模式可以促进多种干预措施的积累。ICU中现有的医疗决策模型描述了个体体征、症状或诊断如何自动导致干预，绕过了在患者可能的结果或治疗偏好的背景下考虑干预价值的机会。我们假设，临床势头影响患者，家庭和医生接受或容忍正在进行的干预，而不考虑可能的结果，最终导致在生命结束时提供不必要的护理。在未来，一个混合方法的研究计划可以完善临床动力的概念模型，衡量其对临床实践的影响，并中断其对生命末期不必要的护理的影响。
Many older adults in the United States receive invasive medical care near the end of life, often in an intensive care unit (ICU). However, most older adults report preferences to avoid this type of medical care and to prioritize comfort and quality of life near death. Wepropose a novel term, "clinical momentum," to describe a system-level, latent, previously unrecognized property of clinical care that may contribute to the provision of unwanted care in the ICU. The example of chronic critical illness illustrates how clinical momentum is generated and propagated during the care of patients with prolonged illness. The ICU is an environment that is generally permissive of intervention, and clinical practice norms and patterns of usual care can promote the accumulation of multiple interventions over time. Existing models of medical decision-making in the ICU describe how individual signs, symptoms, or diagnoses automatically lead to intervention, bypassing opportunities to deliberate about the value of an intervention in the context of a patient's likely outcome or treatment preferences. We hypothesize that clinical momentum influences patients, families, and physicians to accept or tolerate ongoing interventions without consideration of likely outcomes, eventually leading to the delivery of unwanted care near the end of life. In the future, a mixed-methods research program could refine the conceptual model of clinical momentum, measure its impact on clinical practice, and interrupt its influence on unwanted care near the end of life.