Patient and Family Engagement During Treatment Decisions in an ICU: A Discourse Analysis of the Electronic Health Record
Patient and Family Engagement During Treatment Decisions in an ICU: A Discourse Analysis of the Electronic Health Record
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DOI：
10.1097/ccm.0000000000003711
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发表时间：
2019-06-01
影响因子：
8.8
通讯作者：
Schwarze, Margaret L.
中科院分区：
文献类型：
--
作者：
Kruser, Jacqueline M.;Benjamin, Brian T.;Schwarze, Margaret L.
目的：对于面临重大、偏好敏感的治疗决定的重症成人，建议进行共同决策。然而，很少有人知道什么时候以及如何在危重病的纵向过程中，患者和家属参与治疗决策。我们试图通过评估在重症监护室中发展为慢性危重病或死亡的危重成年人的电子健康记录中的临床医生话语来描述治疗决策的模式。设计、设置和患者：我们对2016年1月1日至12月31日期间入住三级医疗中心医学ICU的52名成人患者的电子健康记录进行了定性内容分析，2016.我们纳入了符合慢性危重病共识定义的患者（26例患者）和在ICU中死亡或过渡到临终关怀的匹配样本（26例患者）。干预措施：无。测量和主要结果：ICU住院期间记录的临床医生决策话语的特征。在电子健康记录中，两组临床医生的决策话语都遵循单一的、一致的模式。关于进入ICU的最初决定集中在只能在ICU环境中提供的特定干预（以干预为中心的决定）。入院后，根据生理异常（以生理为中心的决策）指导记录额外治疗的理由。当治疗未能达到指定的生理目标时，临床医生的话语转变为患者和家属参与决策的记录。短语“目标的护理”是常见的电子健康记录，并用于表示预后不良，描述与家庭的冲突，并提供合理的治疗limitation.Conclusions：临床医生的话语在电子健康记录显示，病人的生理学强有力地指导整个纵向过程中的危重病的治疗决策。在可用的医学治疗未能实现生理目标之前，患者和家属参与治疗决策的文件是有限的。
Objectives: Shared decision-making is recommended for critically ill adults who face major, preference-sensitive treatment decisions. Yet, little is known about when and how patients and families are engaged in treatment decision-making over the longitudinal course of a critical illness. We sought to characterize patterns of treatment decision-making by evaluating clinician discourse in the electronic health record of critically ill adults who develop chronic critical illness or die in an ICU.Design, Setting, and Patients: We conducted qualitative content analysis of the electronic health record of 52 adult patients, admitted to a medical ICU in a tertiary medical center from January 1, 2016, to December 31, 2016. We included patients who met a consensus definition of chronic critical illness (26 patients) and a matched sample who died or transitioned to hospice care in the ICU before developing chronic critical illness (26 patients).Interventions: None.Measurements and Main Results: Characterization of clinician decision-making discourse documented during the course of an ICU stay. Clinician decision-making discourse in the electronic health record followed a single, consistent pattern across both groups. Initial decisions about admission to the ICU focused on specific interventions that can only be provided in an ICU environment (intervention-focused decisions). Following admission, the documented rationale for additional treatments was guided by physiologic abnormalities (physiology-centered decisions). Clinician discourse transitioned to documented engagement of patients and families in decision-making when treatments failed to achieve specified physiologic goals. The phrase "goals of care" is common in the electronic health record and is used to indicate poor prognosis, to describe conflict with families, and to provide rationale for treatment limitations.Conclusions: Clinician discourse in the electronic health record reveals that patient physiology strongly guides treatment decision -making throughout the longitudinal course of critical illness. Documentation of patient and family engagement in treatment decision -making is limited until available medical treatments fail to achieve physiologic goals.