Lee M A, Brummel-Smith K, Meyer J, Drew N, London M R
ElderPlace, Home and Community Services Division, Portland, Oregon 97218, USA.
J Am Geriatr Soc. 2000 Oct;48(10):1219-25. doi: 10.1111/j.1532-5415.2000.tb02594.x.
To evaluate whether terminal care was consistent with Physician Orders for Life-Sustaining Treatment (POLST), a preprinted and signed doctor's order specifying treatment instructions in the event of serious illness for CPR, levels of medical intervention, antibiotics, IV fluids, and feeding tubes.
Retrospective chart review.
ElderPlace, a Program of All-Inclusive Care for the Elderly (PACE) site in Portland, Oregon.
All ElderPlace participants who died in 1997 were eligible (n = 58). Reasons for exclusion were no POLST (1), missing POLST (1), and insufficient documentation of care (2).
POLST instructions for each participant and whether or not each of the treatments addressed by the POLST was administered in the final 2 weeks of life.
The POLST specified "do not resuscitate" for 50 participants (93%); CPR use was consistent with these instructions for 49 participants (91%). "Comfort care" was the designated level of medical intervention in 13 cases, "limited interventions" in 18, "advanced interventions" in 18, and "full interventions" in 5. Interventions administered were at the level specified in 25 cases (46%); at a less invasive level in 18 (33%), and at a more invasive level in 11 (20%). Antibiotic administration was consistent with POLST instructions for 86% of 28 subjects who had infections in the last 2 weeks of life, and less invasive for 14%. Care matched POLST instructions in 84% of cases for IV fluids and 94% for feeding tubes.
POLST completion in ElderPlace exceeds reported advance directive rates. Care matched POLST instructions for CPR, antibiotics, IV fluids, and feeding tubes more consistently than previously reported for advance directive instructions. Medical intervention level was consistent with POLST instructions for less than half the participants, however. We conclude that the POLST is effective for limiting the use of some life-sustaining interventions, but that the factors that lead physicians to deviate from patients' stated preferences merit further investigation.
评估临终护理是否与医生下达的维持生命治疗医嘱（POLST）一致，POLST是一份预先印制并签署的医生医嘱，规定了在重病情况下关于心肺复苏、医疗干预水平、抗生素、静脉输液和饲管的治疗指示。
回顾性病历审查。
俄勒冈州波特兰市的老年综合护理项目（PACE）站点ElderPlace。
1997年在ElderPlace去世的所有参与者均符合条件（n = 58）。排除原因包括没有POLST（1例）、POLST缺失（1例）以及护理记录不充分（2例）。
每位参与者的POLST指示，以及POLST所涉及的每项治疗在生命的最后两周是否实施。
POLST为50名参与者（93%）指定了“不要复苏”；49名参与者（91%）的心肺复苏使用情况与这些指示一致。“舒适护理”是13例中指定的医疗干预水平，“有限干预”18例，“高级干预”18例，“全面干预”5例。实施的干预与指定水平相符的有25例（46%）；侵入性较低水平的有18例（33%），侵入性较高水平的有11例（20%）。在生命最后两周感染的28名受试者中，86%的抗生素使用与POLST指示一致，14%的侵入性较低。静脉输液护理在84%的病例中与POLST指示相符，饲管护理在94%的病例中相符。
ElderPlace完成POLST的比例超过了报告的预先指示比例。与先前报告的预先指示相比，护理在心肺复苏、抗生素、静脉输液和饲管方面与POLST指示的匹配度更高。然而，医疗干预水平与POLST指示相符的参与者不到一半。我们得出结论，POLST在限制某些维持生命干预措施的使用方面是有效的，但导致医生偏离患者既定偏好的因素值得进一步研究。
