背景:代理人,代理,和临床医生为失去决策能力的患者做出共同的治疗决策往往不能满足患者的愿望,由于压力,时间压力,误解病人的价值观,投射个人偏见。预先指令旨在使护理与患者价值保持一致,但受限于低完成率和仅适用于医疗决策的子集。这里,在概念验证研究中,我们调查了大型语言模型(LLM)在支持无行为能力患者的重症监护临床决策中纳入患者价值的潜力.
方法:我们模拟了50名决定性的无行为能力患者的基于文本的情景,这些患者的医疗状况需要就特定干预措施做出迫在眉睫的临床决定。对于每个病人来说,我们还模拟了使用替代格式捕获的五个独特的价值概况:数字排名问卷,基于文本的问卷,和自由文本叙述。我们将预训练的生成LLM用于两个任务:1)文本提取正在考虑的治疗方法和2)基于提示的问答以响应场景信息生成建议,提取处理,和患者价值档案。模型输出与三名领域专家的裁决进行了比较,他们独立评估了每个方案和决策。
结论:在88%(n=44/50)的情况下,所讨论的治疗的自动提取是准确的。LLM治疗建议在所有患者中获得了平均李克特评分3.92的5.00分(五个是最好的),因为所有患者都是医学上合理和合理的治疗建议,和5.00中的3.58反映了患者的记录值。当患者值被捕获为短时,分数最高,非结构化,和基于模拟患者资料的自由文本叙述。这个概念验证研究证明了LLM作为代理的支持工具的潜力,代理,和临床医生旨在尊重决定性丧失工作能力的患者的愿望和价值观。
BACKGROUND: Surrogates, proxies, and clinicians making shared treatment decisions for patients who have lost decision-making capacity often fail to honor patients\' wishes, due to stress, time pressures, misunderstanding patient values, and projecting personal biases. Advance directives intend to align care with patient values but are limited by low completion rates and application to only a subset of medical decisions. Here, we investigate the potential of large language models (LLMs) to incorporate patient values in supporting critical care clinical decision-making for incapacitated patients in a proof-of-concept study.
METHODS: We simulated text-based scenarios for 50 decisionally incapacitated patients for whom a medical condition required imminent clinical decisions regarding specific interventions. For each patient, we also simulated five unique value profiles captured using alternative formats: numeric ranking questionnaires, text-based questionnaires, and free-text narratives. We used pre-trained generative LLMs for two tasks: 1) text extraction of the treatments under consideration and 2) prompt-based question-answering to generate a recommendation in response to the scenario information, extracted treatment, and patient value profiles. Model outputs were compared with adjudications by three domain experts who independently evaluated each scenario and decision.
CONCLUSIONS: Automated extractions of the treatment in question were accurate for 88% (n = 44/50) of scenarios. LLM treatment recommendations received an average Likert score by the adjudicators of 3.92 of 5.00 (five being best) across all patients for being medically plausible and reasonable treatment recommendations, and 3.58 of 5.00 for reflecting the documented values of the patient. Scores were highest when patient values were captured as short, unstructured, and free-text narratives based on simulated patient profiles. This proof-of-concept study demonstrates the potential for LLMs to function as support tools for surrogates, proxies, and clinicians aiming to honor the wishes and values of decisionally incapacitated patients.