When patients lack capacity: The roles that patients with terminal diagnoses would choose for their physicians and loved ones in making medical decisions
When patients lack capacity: The roles that patients with terminal diagnoses would choose for their physicians and loved ones in making medical decisions
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DOI：
10.1016/j.jpainsymman.2005.04.010
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发表时间：
2005-10-01
影响因子：
4.7
通讯作者：
Sulmasy, DP
中科院分区：
文献类型：
--
作者：
Nolan, MT;Hughes, M;Sulmasy, DP
人们普遍认为，目前的报废决策方法是不够的。我们通过研究晚期诊断患者如何选择让他们的医生和亲人参与医疗决策来探索这些复杂性，假设他们能够和无法参与。对最近诊断为致命疾病的130例患者进行了横断面采访。患者从两个学术医疗中心招募，使用修改后的决策控制偏好量表，从独立决策到依赖他人的决策。患者被问到在做出医疗决定时，他们将如何平衡自己的意愿与医生和亲人的投入，并权衡亲人相对于医生的投入。大多数患者（52%），假设他们有能力，会选择与他们的医生分享决策，但15%会听从他们的医生，34%会独立做出决定。同样，44%的人会与他们所爱的人分享决策，但更少的人（6%）会听从他们所爱的人。39%的人会依赖医生的判断。如果他们失去意识，他们会选择对他们最好的东西，而不是他们自己的愿望，相比之下，15%的人在意识清醒的情况下会这样做（P < 0.001）。尽管如此，如果患者无意识（33%）比有意识（7%，P = 0.05），患者更有可能权衡他们所爱的人的输入而不是医生的输入。种族、宗教、性别、诊断和健康状况在很大程度上与患者的决策控制偏好无关。晚期诊断的患者报告了各种各样的决策控制偏好，但大多数人会选择与他们的医生和亲人分享决策。如果不能自己决定，他们会转向更依赖医生的意见，而不是自己的意愿，但会更重视亲人的意见。为不能为自己说话的患者做出决定可能比以前在法律、政策或临床伦理中所反映的更为复杂。
Current approaches to end-of-life decision making are widely considered inadequate. We explored these complexities by examining how patients with terminal diagnoses would choose to involve their physicians and loved ones in making medical decisions, assuming they were able and unable to participate. Cross-sectional interviews of 130 patients recently diagnosed with fatal conditions were conducted. Patients were recruited from two academic medical centers using a modification of the Decision Control Preferences Scale, ranging from independent decision making to decision making that relies upon others. Patients were asked how they would balance their own wishes relative to the input of physician and loved ones in making medical decisions, and to weigh the input of loved ones relative to physician. Most patients (52%), assuming they had the capacity, would opt to share decision making with their physicians, but 15% would defer to their physicians and 34% would make decisions independently. Similarly, 44% would share decision making with their loved ones, but fewer (6%) would defer to their loved ones. Thirty-nine percent would rely upon their physicians' judgments about. what would be best for them rather than their own wishes if they became unconscious, compared with 15% who would do so if they were conscious (P < 0.001). Nonetheless, patients were more likely to weigh their loved ones' input more heavily than their physicians' input if they were unconscious (33%) than if they were conscious (7%, P = 0.05). Race, religion, gender, diagnosis, and health status were largely unassociated with patients' decision control preferences. Patients with terminal diagnoses report a wide diversity of decision control preferences, but most would opt to share decision making with their physicians and loved ones. If unable to decide for themselves, they shift toward greater reliance on physician input relative to their own wishes but would weigh loved ones' input more heavily than physician input. Deciding for patients who cannot speak for themselves may be more complex than has previously been reflected in law, policy, or clinical ethics.