目的：本调查的目的是探讨成年患者如何使用限制性指令，他们的家人,临床医生对麻醉期间的复苏状态做出决定。尽管目前的实践指南建议在麻醉前强制重新考虑不要复苏和其他限制性指令，在成人围麻醉期设置中,自动暂停限制护理的指示仍在继续.患者和临床医生如何谈论这些限制性指令在文献中还没有得到充分的研究。
方法：此定性查询使用了Foucauldian后结构案例研究设计。
方法：通过访谈和观察现有的预先指令接受手术的患者来收集数据，家庭成员,和参与他们护理的麻醉期间临床医生。上下文化分析，一种与Foucauldian后结构案例研究设计非常吻合的定性方法，被用来严格检查数据。
结果：27名参与者完成了研究的观察和访谈部分。从另外18名参与者收集观察数据。确定了四种权威话语，这些话语构成了患者和临床医生可用的选择。“我们只是暂停”的话语渗透了麻醉期间的文化，并产生了在临床医生中暂停限制性指令的意愿。关于缺乏时间的话语，除非有必要照顾，否则不要谈论预先指示的愿望，案件中还发现了谁负责解决限制指令的困惑。此外,患者很难将预先的指令选择转化为麻醉前后的环境，这种困难可能会被临床医生误解为与治疗计划一致.最后,电力网络可能会隔离有关患者选择的知识，导致临床医生之间的紧张关系，并为尊重患者的预先指令选择造成障碍。
结论：结果表明，即使存在强制性预先指令重新考虑的政策，患者可能会经历限制他们的选择和决策机构的环境。
OBJECTIVE: The purpose of this inquiry is to explore how adult patients with limiting directives, their families, and clinicians make decisions about resuscitative status during anesthesia. Although current practice guidelines recommend mandatory reconsideration of do not resuscitate and other limiting directives before anesthesia, the automatic suspension of directives limiting care continues in the adult perianesthesia setting. How patients and clinicians talk about these limiting directives is underexplored in the literature.
METHODS: This qualitative inquiry used the Foucauldian Poststructural
Case Study Design.
METHODS: Data were collected through interviews and observation of patients with existing advance directives who underwent surgery, family members, and perianesthesia clinicians who participated in their care. Contextualizing analysis, a qualitative methodology that fits well with Foucauldian Poststructural
Case Study Design, was used to rigorously examine the data.
RESULTS: Twenty-seven participants completed the observation and interview components of the study. Observation data were collected from an additional 18 participants. Four authoritative discourses that constructed choices available to patients and clinicians were identified. The \"We\'ll just suspend\" discourse permeates perianesthesia culture and produces a will to suspend the limiting directive among clinicians. Discourses about lack of time, a desire not to talk about advance directives unless it is essential to care, and confusion about who is responsible for addressing the limiting directive were also identified in the
case. In addition, patients had difficulty translating advance directive choices into the perianesthesia context, and this difficulty may be misunderstood by clinicians as agreement with the plan of care. Finally, power networks may sequester knowledge about patients\' choices, leading to tension among clinicians and creating barriers to honoring patients\' advance directive choices.
CONCLUSIONS: Results suggest that even where policies of mandatory advance directive reconsideration exist, patients may experience environments that constrain their choices and decision-making agency.
