A randomized trial of the effect of patient race on physicians' intensive care unit and life-sustaining treatment decisions for an acutely unstable elder with end-stage cancer.
A randomized trial of the effect of patient race on physicians' intensive care unit and life-sustaining treatment decisions for an acutely unstable elder with end-stage cancer.
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DOI：
10.1097/ccm.0b013e3182186e98
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发表时间：
2011-07
影响因子：
8.8
通讯作者：
Arnold RM
中科院分区：
文献类型：
--
作者：
Barnato AE;Mohan D;Downs J;Bryce CL;Angus DC;Arnold RM
为了测试医院医生是否对患有终末期癌症和危及生命的低氧的非洲裔美国人(AA)和欧洲裔美国人(EA)相同的患者做出了不同的ICU和LST决定。我们使用高保真模拟对患者种族和医生治疗决策之间的关系进行了随机试验。我们通过使用随机排序表随机交替它们的顺序来平衡种族和案例的影响。医生们完成了两次与AA和EA患者模拟器的模拟会面，这些模拟器被诊断出患有预后相同的终末期胃癌或胰腺癌以及危及生命的缺氧和低血压，随后进行了一项关于种族治疗偏好的自我管理调查。我们对每个医生的配对模拟相遇进行了受试者内分析，调整了顺序和病例效应，并对医生的第一次相遇进行了受试者之间的分析，根据病例进行了调整。匹兹堡大学彼得·M·温特模拟教育和研究所。33名医院主治医生，包括12名急诊医生、8名住院医生和13名来自宾夕法尼亚州阿勒格尼县的重症医生。病人模拟器的竞赛。测量包括医生在模拟期间记录的治疗决定，并记录在图表中，以及对种族治疗偏好的信念。当面对AA和EA患者时，医生在诱导插管偏好方面没有不同(对象内比较(WS)：28/32(88%)对28/32(88%)，p=0.589；对象间比较(BS)：13/17(87%)对13/17(76%)，p=0.460)，ICU入院(WS：14/32(44%)对12/32(38%)，p=0.481；BS：8/15(53%)比7/17(41%，p=0.456)、插管(WS：5/32(16%)比4/32(13%)，p=0.567；B：1/15(7%)比4/17(24%)，p=0.215)或仅开始舒适措施(WS：16/32(50%)比19/32(59%)，p=0.681；BS：6/15(40%)比8/17(47%)，p-0.679)。医生们认为，与类似的EA患者相比，患有终末期癌症的AA患者更有可能选择延长生命的化疗，而不是以缓解为主的治疗(67%比，z=−1.79，p=.07)，更愿意使用机械通气延长1周的生命(43%比34%，z=−2.93，p=.003)，如果住院则不太可能需要DNR令(51%比60%，z=3.03，p=.003)。在这项探索性研究中，医院医生没有对其他相同的晚期AA和EA老年人做出不同的治疗决定，尽管他们认为AA患者更有可能更喜欢强化、维持生命的治疗，而且他们严重高估了这两个种族对强化治疗的偏好。
To test whether hospital-based physicians made different ICU and LST decisions for otherwise identical African American (AA) and European American (EA) patients with end-stage cancer and life-threatening hypoxia. We conducted a randomized trial of the relationship between patient race and physician treatment decisions using high-fidelity simulation. We counterbalanced the effects of race and case by randomly alternating their order using a table of random permutations. Physicians completed two simulation encounters with AA and EA patient simulators diagnosed with prognostically-identical end-stage gastric or pancreatic cancer and life-threatening hypoxia and hypotension, followed by a self-administered survey of beliefs regarding treatment preferences by race. We conducted within-subjects analysis of each physician’s matched-pair simulation encounters, adjusting for order and case effects, and between-subjects analysis of physicians’ first encounter, adjusting for case. Peter M. Winter Institute for Simulation Education and Research at the University of Pittsburgh. 33 hospital-based attending physicians, including 12 emergency physicians, 8 hospitalists, and 13 intensivists from Allegheny County, Pennsylvania. Race of patient simulator. Measurements included physician treatment decisions recorded during the simulation and documented in the chart and beliefs about treatment preference by race. When faced with an AA versus a EA patient, physicians did not differ in their elicitation of intubation preferences (within-subject comparison (WS): 28/32 (88%) vs. 28/32 (88%), p=0.589; between-subject comparison (BS): 13/17 (87%) vs. 13/17 (76%), p=0.460), ICU admission (WS: 14/32 (44%) vs. 12/32 (38%), p=0.481; BS: 8/15 (53%) vs. 7/17 (41%), p=0.456), intubation (WS: 5/32 (16%) vs. 4/32 (13%), p=0.567; B: 1/15 (7%) vs. 4/17 (24%), p=0.215) or initiation of comfort measures only (WS: 16/32 (50%) vs. 19/32 (59%), p=0.681; BS: 6/15 (40%) vs. 8/17 (47%), p-0.679). Physicians believed that an AA patient with end-stage cancer was more likely than a similar EA patient to prefer potentially-life prolonging chemotherapy over treatment focused on palliation (67% vs. 64%, z= − 1.79, p=.07) and to want mechanical ventilation for 1 weeks’ life extension (43% vs. 34%, z= − 2.93, p=.003), and less likely to want a DNR order if hospitalized (51% vs. 60%, z= 3.03, p=.003). In this exploratory study, hospital-based physicians did not make different treatment decisions for otherwise identical terminally ill AA and EA elders despite believing that AA patients are more likely to prefer intensive, life-sustaining treatment, and they grossly overestimated the preference for intensive treatment for both races.