Constructing High-stakes Surgical Decisions It's Better to Die Trying
Constructing High-stakes Surgical Decisions It's Better to Die Trying
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DOI：
10.1097/sla.0000000000001081
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发表时间：
2016-01-01
影响因子：
9
通讯作者：
Schwarze, Margaret L.
中科院分区：
文献类型：
--
作者：
Nabozny, Michael J.;Kruser, Jacqueline M.;Schwarze, Margaret L.
目的：从老年人和外科医生的角度探讨高风险手术决策。背景：如果结果是严重的功能障碍，大多数老年慢性病患者会拒绝低风险手术。然而，25% 的医疗保险受益人在生命的最后 3 个月接受过手术，这可能与他们的偏好不一致。患者如何决定进行手术可能会导致不必要的护理问题。方法：我们在威斯康星州麦迪逊和密尔沃基的老年中心召集了 4 个焦点小组和 2 组外科医生，在那里我们播放了一段有关手术和姑息治疗之间选择的视频。我们使用定性内容分析来确定有关临终治疗决策的沟通和解释模型的主题。结果：老年人 (n=37) 和外科医生 (n=17) 一致认为，应最大限度地提高生活质量来指导老年患者的治疗决策。然而，当面临手术和姑息治疗之间的紧急选择时，老年人认为这要么是生与死之间的选择，要么是关于如何死亡的决定。尽管外科医生一致认为非常虚弱的患者不应该接受手术，但他们对治疗方案的提出存在着相互矛盾的观点。结论：老年人和外科医生高度重视生活质量，但这一观念很难纳入紧急手术决策中。一些老年人利用这些价值观来考虑手术和姑息治疗之间的选择，而其他人则认为这是生与死之间的简单选择。外科医生承认制定决策面临的挑战，并描述了促进手术干预的临床势头。
Objective:To explore high-stakes surgical decision making from the perspective of seniors and surgeons.Background:A majority of older chronically ill patients would decline a low-risk procedure if the outcome was severe functional impairment. However, 25% of Medicare beneficiaries have surgery in their last 3 months of life, which may be inconsistent with their preferences. How patients make decisions to have surgery may contribute to this problem of unwanted care.Methods:We convened 4 focus groups at senior centers and 2 groups of surgeons in Madison and Milwaukee, Wisconsin, where we showed a video about a decision regarding a choice between surgery and palliative care. We used qualitative content analysis to identify themes about communication and explanatory models for end-of-life treatment decisions.Results:Seniors (n=37) and surgeons (n=17) agreed that maximizing quality of life should guide treatment decisions for older patients. However, when faced with an acute choice between surgery and palliative care, seniors viewed this either as a choice between life and death or a decision about how to die. Although surgeons agreed that very frail patients should not have surgery, they held conflicting views about presenting treatment options.Conclusions:Seniors and surgeons highly value quality of life, but this notion is difficult to incorporate in acute surgical decisions. Some seniors use these values to consider a choice between surgery and palliative care, whereas others view this as a simple choice between life and death. Surgeons acknowledge challenges framing decisions and describe a clinical momentum that promotes surgical intervention.