重症监护病房(ICU)专业人员在高风险的条件下从事道德决策,巨大的不确定性,时间敏感性和频繁的不可逆性。Casustry是一种通过将患者病例与临床实践经验中的先前病例进行比较来获得可操作知识的方法。然而,在研究领域和实践中,循证医学是主要的认知框架。这项多案例研究评估了重症监护病房(ICU)专业人员在道德案例审议期间对因果关系推理的使用。它在2020年6月至2022年6月期间在两家荷兰医院举行。使用语篇分析记录并分析了来自ICU实践的25个道德案例审议。此外,与参加这些审议的ICU专业人员进行了47次访谈,使用主题分析法进行分析。我们发现ICU专业人员在讨论延续时大量使用病例比较,撤回或限制。类比在证明或复杂化道德判断方面发挥了作用,并在解决道德困境方面发挥了作用。基于案例的论点的语言通常不是公开的规范性。相反,数据显示,因果关系推理涉及医学,综合决策的伦理和上下文要素。MCD的促进者在(支持ICU专业人员)审查因果关系的论点方面起着至关重要的作用。数据显示在MCD期间,实际推理通常与ICU专业人士偏爱的基于原则和规则的推理不同。基于证据的论证通常具有类比论证的特征,特别是当在手的患者被视为在文献中的普通患者中非常独特时。因此,伪装成基于证据的论点的偶然论点可能会给ICU专业人员带来错误的确定性。在教育中,我们应该努力培训临床医生和道德促进者,以便他们能够识别和评估因果关系的论点。
Intensive care unit (ICU) professionals engage in ethical decision making under conditions of high stakes, great uncertainty, time-sensitivity and frequent irreversibility of action. Casuistry is a way by which actionable knowledge is obtained through comparing a patient
case to previous cases from experience in clinical practice. However, within the field of study as well as in practice, evidence-based medicine is the dominant epistemic framework. This multiple case study evaluated the use of casuistic reasoning by intensive care unit (ICU) professionals during moral
case deliberation. It took place in two Dutch hospitals between June 2020 and June 2022. Twentyfive moral
case deliberations from ICU practice were recorded and analyzed using discourse analysis. Additionally, 47 interviews were held with ICU professionals who participated in these deliberations, analyzed using thematic analysis. We found that ICU professionals made considerable use of
case comparisons when discussing continuation, withdrawal or limitation. Analogies played a role in justifying or complicating moral judgements, and also played a role in addressing moral distress. The language of
case-based arguments is most often not overtly normative. Rather, the data shows that casuistic reasoning deals with the medical, ethical and contextual elements of decisions in an integrated manner. Facilitators of MCD have an essential role in (supporting ICU professionals in) scrutinizing casuistic arguments. The data shows that during MCD, actual reasoning often deviated from principle- and rule-based reasoning which ICU professionals preferred themselves. Evidence-based arguments often gained the character of analogical arguments, especially when a patient-at-hand was seen as highly unique from the average patients in the literature. Casuistic arguments disguised as evidence-based arguments may therefore provide ICU professionals with a false sense of certainty. Within education, we should strive to train clinicians and ethics facilitators so that they can recognize and evaluate casuistic arguments.