ICU CULTURE AND PROBLEMATIC TREATMENT LIMITATION CASES

这项研究的目的是描述四个ICU的文化背景，并发展和比较患者、家庭和医疗保健提供者的同时代观点以及他们与临终决策的关系。有证据表明，卫生保健提供者和患者之间关于预后、复苏和患者偏好的临终沟通很差，并且缺乏对患者拒绝护理的执行。拟议的定性研究旨在集中关注四个成人重症监护病房(ICU)中有问题的限制(扣留/撤回)护理；ICU是大部分此类决策的地点。有问题的决定是指提供者和患者或家庭之间或这些群体内部存在分歧的决定。没有问题的案例也将作为这类护理的一部分进行研究。这是一项带有嵌入案例研究的前瞻性人种学研究。数据收集方法将包括对四个ICU的参与者观察和对提供者、患者和家属的半结构化访谈，以提供(A)关于每个单元在生命结束问题上的文化的信息，并提供(B)了解不同参与者对限制治疗决定的实时观点，这些观点将用于制定多个案例研究。这种方法应该确定良好决策的障碍和促进者。通过对这些障碍和促进者的描述，将有可能设计出符合患者利益并为患者、家属和卫生保健提供者共同接受的干预措施。

The objectives of this study are to describe the cultural context of four ICUs and to develop and compare contemporaneous perspectives of patients, families, and health care providers and their relationship to end- of-life decision making. There is evidence of poor end-of-life communication between health care providers and patients about prognosis, resuscitation, and patient preferences, and lack of implementation of patient refusals of care. The proposed qualitative study is designed to focus intensively on problematic limiting (withholding/withdrawing) of care in four adult intensive care units (ICUs); ICUs are the site of much of this type of decision making. Problematic decisions are those where there is disagreement between providers and patients or families or within these groups. Non- problematic cases will also be studied as part of the context of such care. This is a prospective ethnographic study with embedded case studies. Data collection methods will include participant observation on the four ICUs and semi-structured interviews of providers, patients, and families to provide (a) information about each unit's culture with respect to end- of-life issues, and to provide (b) an understanding of varying participants' real time perspectives on limitation of treatment decisions, which will be used to develop multiple case studies. This approach should identify barriers to and facilitators of good decision making. With a description of such barriers and facilitators, it will be possible to design interventions to serve patients' interests and be mutually acceptable to patients, families, and health care providers.