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[JAMA在线发表]:1996年至2016年欧洲ICU临终治疗实践的改变
2019年10月11日 时讯速递, 进展交流 暂无评论

Original Investigation Caring for the Critically Ill PatientOctober 2, 2019

Changes in End-of-Life Practices in European Intensive Care Units From 1999 to 2016

Charles L. Sprung, Bara Ricou, Christiane S. Hartog, et al

JAMA. Published online October 2, 2019. doi:10.1001/jama.2019.14608

Importance 背景

End-of-life decisions occur daily in intensive care units (ICUs) around the world, and these practices could change over time.

生命终末期决策在全球ICU内每天都在发生,其行为可能随时间而改变。

Objective 目的

To determine the changes in end-of-life practices in European ICUs after 16 years.

确定16年后欧洲ICU中临终治疗实践的改变

Design, Setting, and Participants 试验设计,场景及研究人群

Ethicus-2 was a prospective observational study of 22 European ICUs previously included in the Ethicus-1 study (1999-2000). During a self-selected continuous 6-month period at each ICU, consecutive patients who died or had any limitation of life-sustaining therapy from September 2015 until October 2016 were included. Patients were followed up until death or until 2 months after the first treatment limitation decision.

Ethicus-2是对于Ethicus-1研究(1999-2000)中纳入的22个欧洲ICU进行的一项前瞻观察性研究。2015年9月至2016年10月间,每个ICU自行选择连续6个月作为研究期限,期间连续死亡或采取任何限制生命支持治疗措施的患者入选。患者随访至死亡或首次作出限制治疗决定后2个月。

Exposures 暴露因素

Comparison between the 1999-2000 cohort vs 2015-2016 cohort.

1999-2000队列与2015-2016队列的比较

Main Outcomes and Measures 主要预后指标

End-of-life outcomes were classified into 5 mutually exclusive categories (withholding of life-prolonging therapy, withdrawing of life-prolonging therapy, active shortening of the dying process, failed cardiopulmonary resuscitation [CPR], brain death). The primary outcome was whether patients received any treatment limitations (withholding or withdrawing of life-prolonging therapy or shortening of the dying process). Outcomes were determined by senior intensivists.

临终预后分为相互排斥的5种情况(限制生命支持治疗强度,撤除生命支持治疗,主动缩短死亡过程,心肺复苏[CPR]失败,脑死亡)。主要预后指标为患者是否接受任何限制治疗的措施(限制治疗强度或撤除治疗或缩短死亡过程)。由高年ICU医生确定预后。

Results 结果

Of 13 625 patients admitted to participating ICUs during the 2015-2016 study period, 1785 (13.1%) died or had limitations of life-prolonging therapies and were included in the study. Compared with the patients included in the 1999-2000 cohort (n = 2807), the patients in 2015-2016 cohort were significantly older (median age, 70 years [interquartile range {IQR}, 59-79] vs 67 years [IQR, 54-75]; P < .001) and the proportion of female patients was similar (39.6% vs 38.7%; P = .58). Significantly more treatment limitations occurred in the 2015-2016 cohort compared with the 1999-2000 cohort (1601 [89.7%] vs 1918 [68.3%]; difference, 21.4% [95% CI, 19.2% to 23.6%]; P < .001), with more withholding of life-prolonging therapy (892 [50.0%] vs 1143 [40.7%]; difference, 9.3% [95% CI, 6.4% to 12.3%]; P < .001), more withdrawing of life-prolonging therapy (692 [38.8%] vs 695 [24.8%]; difference, 14.0% [95% CI, 11.2% to 16.8%]; P < .001), less failed CPR (110 [6.2%] vs 628 [22.4%]; difference, −16.2% [95% CI, −18.1% to −14.3%]; P < .001), less brain death (74 [4.1%] vs 261 [9.3%]; difference, −5.2% [95% CI, −6.6% to −3.8%]; P < .001) and less active shortening of the dying process (17 [1.0%] vs 80 [2.9%]; difference, −1.9% [95% CI, 2.7% to −1.1%]; P < .001).

在2015-2016研究期间,共有13 625名患者收入参研ICU,其中1785名 (13.1%) 患者死亡或限制生命支持治疗,因而纳入本研究。与1999-2000队列纳入患者(n = 2807)相比,2015-2016队列患者年龄更大 (中位年龄, 70 岁 [四分位区间 {IQR}, 59-79] vs 67 岁 [IQR, 54-75]; P < .001),女性患者比例相似 (39.6% vs 38.7%; P = .58)。2015-2016队列患者较1999-2000队列接受了更多的治疗限制 (1601 [89.7%] vs 1918 [68.3%]; 差异, 21.4% [95% CI, 19.2% to 23.6%]; P < .001),更多限制生命支持治疗强度 (892 [50.0%] vs 1143 [40.7%]; 差异, 9.3% [95% CI, 6.4% to 12.3%]; P < .001),更多撤出生命支持治疗 (692 [38.8%] vs 695 [24.8%]; 差异, 14.0% [95% CI, 11.2% to 16.8%]; P < .001),CPR失败更少 (110 [6.2%] vs 628 [22.4%]; 差异, −16.2% [95% CI, −18.1% to −14.3%]; P < .001),脑死亡更少 (74 [4.1%] vs 261 [9.3%]; 差异, −5.2% [95% CI, −6.6% to −3.8%]; P < .001),主动缩短死亡过程更少 (17 [1.0%] vs 80 [2.9%]; 差异, −1.9% [95% CI, 2.7% to −1.1%]; P < .001)。

Conclusions and Relevance 结论与意义

Among patients who had treatment limitations or died in 22 European ICUs in 2015-2016, compared with data reported from the same ICUs in 1999-2000, limitations in life-prolonging therapies occurred significantly more frequently and death without limitations in life-prolonging therapies occurred significantly less frequently. These findings suggest a shift in end-of-life practices in European ICUs, but the study is limited in that it excluded patients who survived ICU hospitalization without treatment limitations.

欧洲22个ICU中限制治疗或死亡的患者中,与1999-2000年相同ICU报告的数据相比,2015-2016年间限制生命支持治疗的情况更为普遍,而未限制生命支持治疗的死亡更少发生。这些结果提示,欧洲ICU的临终治疗实践发生了改变,但是,研究局限性在于排除了那些没有限制治疗且存活的ICU患者。

评论[仅代表个人观点]

  • 医学伦理问题是被国内重症医学界忽视的领域
  • 尽管医生的重要职责之一是治愈疾病和患者,但是,如何改进患者生活质量,尊重患者自身意愿,减少死亡过程的痛苦,ICU医生无疑也是责无旁贷的
  • 在医学伦理方面,国内ICU护理同仁已经走在了临床医生前面,需要我们反思和学习

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