Decision-making for percutaneous endoscopic gastrostomy among older adults in a community setting
Decision-making for percutaneous endoscopic gastrostomy among older adults in a community setting
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DOI：
10.1111/j.1532-5415.1999.tb05235.x
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发表时间：
1999-09-01
影响因子：
6.3
通讯作者：
Nisi, R
中科院分区：
文献类型：
--
作者：
Callahan, CM;Haag, KM;Nisi, R
目的：从患者、护理人员和医生的角度描述经皮内窥镜胃造口术的临床决策。设计：一项前瞻性队列研究。设置和患者：所有 60 岁及以上的患者在 16 个月的时间内在特定社区接受经皮内窥镜胃造口术。主要结果指标：患者或其代理决策者完成半结构化面对面访谈，以绘制地图明确信息收集过程、期望和参与决定是否进行胃造口喂养的讨论者。医生完成了一份书面调查问卷，以确定他们推荐经皮内窥镜胃造口术的可能性、他们对决策和推荐过程的参与以及决策中感受到的压力来源。 结果：我们确定了在研究窗口期间接受经皮内窥镜胃造口术的 100 名患者和在指定社区提供护理的 82 名初级保健医生。进行该手术的最常见原因是中风、神经系统疾病和癌症。患者或其代理决策者报告称，在做出进行人工喂养的决定时，有多个讨论者、不完整的信息以及相当大的痛苦。这种痛苦通常是在患有急性且令人衰弱的疾病的情况下发生的，这种疾病常常掩盖了人工喂养的决定。胃造口术的决定往往看起来是一个“非决定”，因为决策者几乎没有其他选择。医生们还报告说，在提出进行经皮内窥镜胃造口术的建议时遇到了相当大的困扰，包括来自家庭或其他医疗保健专业人员的压力。医生对经皮内窥镜胃造口术有明确的分诊模式，但这些模式背后的假设并没有得到医学文献的充分支持。结论：患者、护理人员和医生常常被迫在悲惨的情况下和信息不完整的情况下做出关于长期肠内喂养的决定。决策者通常看不到任何可接受的替代方案。由于缺乏有关这些患者长期功能结果的数据，决策者似乎主要关注手术的短期安全性和改善营养的潜力。
OBJECTIVE: To describe clinical decision-making for percutaneous endoscopic gastrostomy from the perspective of patients, caregivers, and physicians.DESIGN: A prospective cohort study.SETTING AND PATIENTS: All patients aged 60 and older receiving percutaneous endoscopic gastrostomies in a defined community over a 16-month period.MAIN OUTCOMES MEASURES: Either patients or their surrogate decision-makers completed a semistructured face-to-face interview to map out the information gathering process, expectations, and discussants involved in the decision to proceed with gastrostomy feeding. Physicians completed a written questionnaire to determine their likelihood of recommending percutaneous endoscopic gastrostomy, their involvement in the decision-making and recommendation process, and sources of perceived pressure in the decisionmaking.RESULTS: We identified 100 patients who received percutaneous endoscopic gastrostomy during the study window and 82 primary care physicians who provided care in the defined community. The most common reasons for the procedure were stroke, neurologic disease, and cancer. Patients or their surrogate decision-makers reported multiple discussants, incomplete information, and considerable distress in arriving at the decision to proceed with artificial feeding. This distress was usually in the context of an acute and debilitating illness that often overshadowed the decision about artificial feeding. The decision for gastrostomy often appeared to be a "non-decision" in the sense that decision-makers perceived few alternatives. Physicians also reported considerable distress in arriving at recommendations to proceed with percutaneous endoscopic gastrostomy, including perceived pressures from families or other healthcare professionals. Physicians have clear patterns of triage for percutaneous endoscopic gastrostomy, but the assumptions underlying these patterns are not well supported by the medical literature.CONCLUSIONS: Patients, caregivers, and physicians are often compelled to make decisions about long-term enteral feeding under tragic circumstances and with incomplete information. Decision-makers typically do not perceive any acceptable alternatives. Because data on these patients' long term functional outcomes are lacking, decision-makers appear to focus primarily on the short-term safety of the procedure and the potential for improved nutrition.