Molloy D W, Guyatt G H, Russo R, Goeree R, O'Brien B J, Bédard M, Willan A, Watson J, Patterson C, Harrison C, Standish T, Strang D, Darzins P J, Smith S, Dubois S
Department of Medicine, McMaster University, Ontario, Canada.
JAMA. 2000 Mar 15;283(11):1437-44. doi: 10.1001/jama.283.11.1437.
Although advance directives are commonly used in the community, little is known about the effects of their systematic implementation.
To examine the effect of systematically implementing an advance directive in nursing homes on patient and family satisfaction with involvement in decision making and on health care costs.
Randomized controlled trial conducted June 1, 1994, to August 31, 1998.
A total of 1292 residents in 6 Ontario nursing homes with more than 100 residents each.
The Let Me Decide advance directive program included educating staff in local hospitals and nursing homes, residents, and families about advance directives and offering competent residents or next-of-kin of mentally incompetent residents an advance directive that provided a range of health care choices for life-threatening illness, cardiac arrest, and nutrition. The 6 nursing homes were pair-matched on key characteristics, and 1 home per pair was randomized to take part in the program. Control nursing homes continued with prior policies concerning advance directives.
Residents' and families' satisfaction with health care and health care services utilization over 18 months, compared between intervention and control nursing homes.
Of 527 participating residents in intervention nursing homes, 49% of competent residents and 78% of families of incompetent residents completed advance directives. Satisfaction was not significantly different in intervention and control nursing homes. The mean difference (scale, 1-7) between intervention and control homes was -0.16 (95 % confidence interval [CI], -0.41 to 0.10) for competent residents and 0.07 (95% CI, -0.08 to 0.23) for families of incompetent residents. Intervention nursing homes reported fewer hospitalizations per resident (mean, 0.27 vs 0.48; P = .001) and less resource use (average total cost per patient, Can $3490 vs Can $5239; P = .01) than control nursing homes. Proportion of deaths in intervention (24%) and control (28%) nursing homes were similar (P = .20).
Our data suggest that systematic implementation of a program to increase use of advance directives reduces health care services utilization without affecting satisfaction or mortality.
尽管预立医疗指示在社区中普遍使用，但对于其系统实施的效果却知之甚少。
研究在养老院系统实施预立医疗指示对患者及其家属参与决策的满意度以及医疗保健成本的影响。
1994年6月1日至1998年8月31日进行的随机对照试验。
安大略省6家养老院的1292名居民，每家养老院居民均超过100人。
“让我决定”预立医疗指示项目包括对当地医院和养老院的工作人员、居民及其家属进行预立医疗指示方面的教育，并向有行为能力的居民或无行为能力居民的近亲提供一份预立医疗指示，其中针对危及生命的疾病、心脏骤停和营养问题提供了一系列医疗保健选择。6家养老院根据关键特征进行配对，每对中的1家随机参与该项目。对照养老院继续沿用先前关于预立医疗指示的政策。
比较干预组和对照组养老院中居民及其家属在18个月内对医疗保健和医疗保健服务利用情况的满意度。
在干预组养老院的527名参与居民中，49%有行为能力的居民和78%无行为能力居民的家属完成了预立医疗指示。干预组和对照组养老院的满意度无显著差异。有行为能力居民中，干预组和对照组养老院之间的平均差异（量表，1 - 7）为 - 0.16（95%置信区间[CI]，- 0.41至0.10），无行为能力居民的家属中该差异为0.07（95%CI，- 0.08至0.23）。与对照养老院相比，干预组养老院报告的每位居民住院次数更少（平均，0.27对0.48；P = 0.001），资源使用更少（每位患者平均总成本，3490加元对5239加元；P = 0.01）。干预组（24%）和对照组（28%）养老院的死亡比例相似（P = 0.20）。
我们的数据表明，系统实施一项增加预立医疗指示使用的项目可降低医疗保健服务的利用率，且不影响满意度或死亡率。
