A Scenario-Based, Randomized Trial of Patient Values and Functional Prognosis on Intensivist Intent to Discuss Withdrawing Life Support
A Scenario-Based, Randomized Trial of Patient Values and Functional Prognosis on Intensivist Intent to Discuss Withdrawing Life Support
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DOI：
10.1097/ccm.0000000000000227
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发表时间：
2014-06-01
影响因子：
8.8
通讯作者：
Needham, Dale M.
中科院分区：
文献类型：
--
作者：
Turnbull, Alison E.;Krall, Jenna R.;Needham, Dale M.
目的：评估1)家属表达的患者价值和2)记录患者功能预后的要求对重症医师在假设的家庭会议上讨论撤销生命支持的意图的影响。设计：三组随机试验。环境：179家美国医院的重症监护培训项目获得了研究生医学教育认证委员会的认可。研究对象：通过电子邮件邀请从1850名合格的学术重症医师数据库中招募630名重症医师。干预措施：每位重症监护员被随机分配到一个假想的病人（X夫人），在网上回顾10个具有一系列疾病严重程度的临床情景。在对照组的情况下，病人不希望在没有合理的独立生活机会的情况下继续维持生命。在第一个实验组中，无论功能结果如何，患者都需要生命支持。在第二个实验组中，患者的数值与对照组相同，但强化医生需要记录患者3个月的功能预后。测量和主要结果：对问题的回答：您会向X女士的家人提出撤销生命维持系统的可能性吗？用李克特五点量表回答。患者值对重症监护医师是否打算讨论停止生命支持没有影响（p = 0.81），但随机记录功能预后的重症监护医师讨论停止生命支持的可能性要高49% （95% CI, 20-85%）。结论：在这个全国性的、基于场景的随机试验中，患者的价值对重症监护医师与家人讨论撤销生命支持的决定没有影响。然而，要求重症监护医师记录患者3个月的估计功能结果大大增加了他们讨论停药的意愿。
Objectives: To evaluate the effect of 1) patient values as expressed by family members and 2) a requirement to document patients' functional prognosis on intensivists' intention to discuss withdrawal of life support in a hypothetical family meeting.Design: A three-armed, randomized trial.Setting: One hundred seventy-nine U.S. hospitals with training programs in critical care accredited by the Accreditation Council for Graduate Medical Education.Subjects: Six hundred thirty intensivists recruited via e-mail invitation from a database of 1,850 eligible academic intensivists.Interventions: Each intensivist was randomized to review 10, online, clinical scenarios with a range of illness severities involving a hypothetical patient (Mrs. X). In control-group scenarios, the patient did not want continued life support without a reasonable chance of independent living. In the first experimental arm, the patient wanted life support regardless of functional outcome. In the second experimental arm, patient values were identical to the control group, but intensivists were required to record the patient's estimated 3-month functional prognosis.Measurements and Main Results: Response to the question: Would you bring up the possibility of withdrawing life support with Mrs. X's family? answered using a five-point Likert scale. There was no effect of patient values on whether intensivists intended to discuss withdrawal of life support (p = 0.81), but intensivists randomized to record functional prognosis were 49% more likely (95% CI, 20-85%) to discuss withdrawal.Conclusions: In this national, scenario-based, randomized trial, patient values had no effect on intensivists' decisions to discuss withdrawal of life support with family. However, requiring intensivists to record patients' estimated 3-month functional outcome substantially increased their intention to discuss withdrawal.