Physicians' attitudes toward end-of-life decisions in amyotrophic lateral sclerosis
Physicians' attitudes toward end-of-life decisions in amyotrophic lateral sclerosis
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DOI：
10.1080/21678421.2018.1536154
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发表时间：
2019-01-02
影响因子：
2.8
通讯作者：
Anneser, Johanna
中科院分区：
文献类型：
--
作者：
Thurn, Tamara;Borasio, Gian Domenico;Anneser, Johanna
目的：(1)评估医生对肌萎缩侧索硬化症(ALS)患者的临终关怀(EOL)的态度，包括放弃人工营养和水化(FANH)、持续镇静直至死亡(CSD)和撤除有创呼吸机(WIV)，以及对医生协助的死亡(PAD)包括医生协助自杀和安乐死的态度；(2)探讨影响这些态度的因素。方法：我们使用两个描述ALS患者不同疾病进展阶段的临床场景来评估痛苦(生理/心理存在)对对WIV态度的影响，以及痛苦和预后(短期/长期)对FANH、CSD和PAD态度的影响。结果：来自欧洲ALS中心和神经内科的50名医生完成了我们的调查。短期预后对接受剖宫产(p=0.014)和剖腹产(p=0.048)的态度有积极影响，对施行剖腹产(p=0.036)和安乐死(p=0.023)的态度也有积极影响。以心理存在主义为主的痛苦与对WIV更有利的态度有关，但对实施CSD的态度有负面影响。回归分析表明，宗教信仰与对姑息性EOL实践和PAD更不情愿的态度有关，而姑息护理培训仅与对姑息性EOL实践的更有利态度相关。结论：ALS医生似乎承认精神存在痛苦是WIV的高度可接受的动机，但不是CSD。医生似乎对回应病人的要求很满意，但更不愿意在决策过程中扮演积极主动的角色。姑息治疗培训可能会在这些具有挑战性的情况下为ALS医生提供支持。
Objective: This study aims (1) to assess physicians' attitudes toward different palliative end-of-life (EOL) practices in amyotrophic lateral sclerosis (ALS) care, including forgoing artificial nutrition and hydration (FANH), continuous sedation until death (CSD), and withdrawing invasive ventilation (WIV), and toward physician-assisted dying (PAD) including physician-assisted suicide and euthanasia and (2) to explore variables influencing these attitudes. Methods: We used two clinical vignettes depicting ALS patients in different stages of their disease progression to assess the influence of suffering (physical/psycho-existential) on attitudes toward WIV and the influence of suffering and prognosis (short-term/long-term) on attitudes toward FANH, CSD, and PAD. Results: 50 physicians from European ALS centers and neurological departments completed our survey. Short-term prognosis had a positive impact on attitudes toward offering FANH (p = 0.014) and CSD (p = 0.048) as well as on attitudes toward performing CSD (p = 0.036) and euthanasia (p = 0.023). Predominantly psycho-existential suffering was associated with a more favorable attitude toward WIV but influenced attitudes toward performing CSD negatively. Regression analysis showed that religiosity was associated with more reluctant attitudes toward palliative EOL practices and PAD, whereas training in palliative care was associated with more favorable attitudes toward palliative EOL practices only. Conclusion: ALS physicians seem to acknowledge psycho-existential suffering as a highly acceptable motive for WIV but not CSD. Physicians appear to be comfortable with responding to the patient's requests, but more reluctant to assume a proactive role in the decision-making process. Palliative care training may support ALS physicians in these challenging situations.