Disagreement Between Clinicians and Score in Decision-Making Capacity of Critically Ill Patients*
Disagreement Between Clinicians and Score in Decision-Making Capacity of Critically Ill Patients*
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DOI：
10.1097/ccm.0000000000003550
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发表时间：
2019-03-01
影响因子：
8.8
通讯作者：
Lautrette, Alexandre
中科院分区：
文献类型：
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作者：
Bertrand, Pierre-Marie;Pereira, Bruno;Lautrette, Alexandre
目的：比较由主治临床医生（医生、护士和住院医师）对ICU患者决策能力的评估与由简易精神状态检查测量的能力评分，必要时由能力评估辅助工具完成。主要结果是医生的评估和评分之间的一致性。次要结果是护士或住院医师评估之间的一致性，以及与分歧相关的因素的评分和识别。设计：为期1天的患病率研究。设置：法国的19个ICU。受试者：研究当天在ICU住院的所有患者和主治医生。干预措施：患者的决策能力由主治医生和独立的观察员使用的分数进行评估。测量和主要结果：共有206名患者进行了评估，由213名主治医生（57名医生，97名护士，和59名居民）。医生指定有决策能力的患者（n = 92/ 206 [ 45%]）多于评分（n = 34/206 [17%];绝对差异28% [95% CI，20-37%]; p = 0.001）。所有临床医生的评估与评分之间存在高度不一致（Kappa系数：医生为0.39 [95%CI，0.29-0.50];护士为0.39 [95%CI，0.27-0.52];住院医师为0.46 [95%CI，0.35-0.58]）。与分歧相关的主要因素是格拉斯哥昏迷量表评分在10到15之间（医生的优势比为2.92 [1.18-7.19]，p = 0.02;护士的优势比为4.97 [1.50-16.45]，p = 0.01;和3.39 [1.12-10.29]，住院医生p = 0.03），而不区分格拉斯哥昏迷量表评分10 - 15。结论：与评分相比，ICU患者的决策能力被所有主治医生大大高估。与分歧相关的主要因素是格拉斯哥昏迷量表评分在10到15之间，表明临床医生混淆了意识和决策能力。
Objectives: To compare the assessment of decision-making capacity of ICU patients by attending clinicians (physicians, nurses, and residents) with a capacity score measured by the Mini-Mental Status Examination, completed by Aid to Capacity Evaluation if necessary. The primary outcome was agreement between physicians' assessments and the score. Secondary outcomes were agreement between nurses' or residents' assessments and the score and identification of factors associated with disagreement. Design: A 1-day prevalence study. Setting: Nineteen ICUs in France. Subjects: All patients hospitalized in the ICU on the study day and the attending clinicians. Interventions: The decision-making capacity of patients was assessed by the attending clinicians and independently by an observer using the score. Measurements and Main Results: A total of 206 patients were assessed by 213 attending clinicians (57 physicians, 97 nurses, and 59 residents). Physicians designated more patients as having decision-making capacity (n = 92/ 206 [ 45%]) than score (n = 34/206 [17%]; absolute difference 28% [95% CI, 20-37%]; p = 0.001). There was a high disagreement between assessments of all clinicians and score (Kappa coefficient 0.39 [95% CI, 0.29-0.50] for physicians; 0.39 [95% CI, 0.27-0.52] for nurses; and 0.46 [95% CI, 0.35-0.58] for residents). The main factor associated with disagreement was a Glasgow Coma Scale score between 10 and 15 (odds ratio, 2.92 [1.18-7.19], p = 0.02 for physicians; 4.97 [1.50-16.45], p = 0.01 for nurses; and 3.39 [1.12-10.29], p = 0.03 for residents) without differentiating between the Glasgow Coma Scale scores from 10 to 15. Conclusions: The decision-making capacity of ICU patients was largely overestimated by all attending clinicians as compared with a score. The main factor associated with disagreement was a Glasgow Coma Scale score between 10 and 15, suggesting that clinicians confused consciousness with decision-making capacity.