Rabow Michael W, Dibble Suzanne L, Pantilat Steven Z, McPhee Stephen J
Department of Medicine, University of California, San Francisco, CA 94115, USA.
Arch Intern Med. 2004 Jan 12;164(1):83-91. doi: 10.1001/archinte.164.1.83.
Little is known about the use of palliative care for outpatients who continue to pursue treatment of their underlying disease or whether outpatient palliative medicine consultation teams improve clinical outcomes.
We conducted a year-long controlled trial involving 50 intervention patients and 40 control patients in a general medicine outpatient clinic. Primary care physicians referred patients with advanced congestive heart failure, chronic obstructive pulmonary disease, or cancer who had a prognosis ranging from 1 to 5 years. In the intervention group, the primary care physicians received multiple palliative care team consultations, and patients received advance care planning, psychosocial support, and family caregiver training. Clinical and health care utilization outcomes were assessed at 6 and 12 months.
Groups were similar at baseline. Similar numbers of patients died during the study year (P =.63). After the intervention, intervention group patients had less dyspnea (P =.01) and anxiety (P =.05) and improved sleep quality (P =.05) and spiritual well-being (P =.007), but no change in pain (P =.41), depression (P =.28), quality of life (P =.43), or satisfaction with care (P =.26). Few patients received recommended analgesic or antidepressant medications. Intervention patients had decreased primary care (P =.03) and urgent care visits (P =.04) without an increase in emergency department visits, specialty clinic visits, hospitalizations, or number of days in the hospital. There were no differences in charges (P =.80).
Consultation by a palliative medicine team led to improved patient outcomes in dyspnea, anxiety, and spiritual well-being, but failed to improve pain or depression. Palliative care for seriously ill outpatients can be effective, but barriers to implementation must be explored.
对于继续接受基础疾病治疗的门诊患者使用姑息治疗的情况，以及门诊姑息医学咨询团队是否能改善临床结局，我们了解得很少。
我们在一家普通内科门诊进行了一项为期一年的对照试验，涉及50名干预组患者和40名对照组患者。初级保健医生转诊了患有晚期充血性心力衰竭、慢性阻塞性肺疾病或癌症且预后为1至5年的患者。在干预组中，初级保健医生接受了多次姑息治疗团队的咨询，患者接受了预先护理计划、心理社会支持和家庭护理人员培训。在6个月和12个月时评估临床和医疗保健利用结局。
两组在基线时相似。在研究年度内死亡的患者数量相似（P = 0.63）。干预后，干预组患者的呼吸困难（P = 0.01）和焦虑（P = 0.05）减轻，睡眠质量（P = 0.05）和精神健康（P = 0.007）改善，但疼痛（P = 0.41）、抑郁（P = 0.28）、生活质量（P = 0.43）或护理满意度（P = 0.26）无变化。很少有患者接受推荐的镇痛药或抗抑郁药。干预组患者的初级保健就诊次数（P = 0.03）和紧急护理就诊次数（P = 0.04）减少，而急诊就诊次数、专科门诊就诊次数、住院次数或住院天数没有增加。费用方面没有差异（P = 0.80）。
姑息医学团队的咨询改善了患者在呼吸困难、焦虑和精神健康方面的结局，但未能改善疼痛或抑郁。对重症门诊患者的姑息治疗可能是有效的，但必须探索实施过程中的障碍。
