Jerant Anthony F, Azari Rahman S, Nesbitt Thomas S, Edwards-Goodbee Adrienne, Meyers Frederick J
Department of Family and Community Medicine, University of California Davis School of Medicine, 4860 Y Street, Suite 2300, Sacramento, CA 95817, USA.
Soc Sci Med. 2006 Jan;62(1):199-207. doi: 10.1016/j.socscimed.2005.05.010. Epub 2005 Jun 28.
Troubling deficits exist in palliative care (PC) of older adults under the prevailing "terminal care"-oriented model. We previously described a PC model--TLC--that provides a blueprint for remedying these shortfalls. In this model, PC is envisioned as Timely and Team-oriented, Longitudinal, and Collaborative and Comprehensive. We present results of the Palliative Care in Assisted Living pilot, comparing two TLC model-based, facility delivered interventions for improving the PC of elderly assisted living residents in Sacramento, California, a growing and under-researched population. The less intensive intervention involved one assessment followed by a PC improvement recommendation letter to the resident, family member, primary provider, and facility staff, while the more intensive intervention involved assessments and letters every three months. Primary outcomes were SF-36 Physical (PCS) and Mental (MCS) Component scores and recommendation adherence. Eighty-one subjects enrolled (mean age 85), 58 in the more and 23 in the less intensive group. A loved one attended 56% of baseline assessments. Most subjects expressed a preference for maintaining current quality of life over prolonging life at reduced quality. None were eligible for hospice care. A total of 418 recommendations (mean 5.1 per subject) were generated concerning symptoms, mood, functional impairments, and advance directives. We found no significant differences in recommendation adherence between more (42%) and less (44%) intensive groups, and no significant changes in PCS and MCS scores within or between groups. However, a loved one's attendance of the baseline assessment was associated with improved PCS scores (p=0.04). Our pilot study had methodological limitations that could account for the lack of significant outcome effects. In this context, and given the myriad unmet PC needs we detected, interventions based on the TLC model might allow delivery of timely PC to assisted living residents not eligible for hospice care. Further studies exploring the TLC model appear warranted.
在当前以“临终关怀”为导向的模式下，老年患者的姑息治疗（PC）存在令人担忧的不足。我们之前描述了一种PC模式——TLC，它为弥补这些不足提供了蓝图。在该模式中，PC被设想为及时且以团队为导向、纵向、协作且全面的。我们展示了辅助生活环境中的姑息治疗试点项目的结果，比较了两种基于TLC模式、在机构中实施的干预措施，以改善加利福尼亚州萨克拉门托市老年辅助生活居民的PC状况，这是一个不断增长且研究不足的人群。强度较低的干预包括一次评估，随后向居民、家庭成员、初级医疗服务提供者和机构工作人员发送一份PC改善推荐信，而强度较高的干预则每三个月进行一次评估并发送信件。主要结局指标是SF - 36身体（PCS）和精神（MCS）成分得分以及推荐信的依从性。81名受试者入组（平均年龄85岁），58名在强度较高组，23名在强度较低组。56%的基线评估有亲人陪同。大多数受试者表示更倾向于维持当前生活质量而非以降低质量为代价延长生命。无人符合临终关怀条件。共产生了418条关于症状、情绪、功能障碍和预先医疗指示的建议（平均每人5.1条）。我们发现强度较高组（42%）和强度较低组（44%）在建议依从性方面无显著差异，组内和组间的PCS和MCS得分也无显著变化。然而，亲人出席基线评估与PCS得分改善相关（p = 0.04）。我们的试点研究存在方法学局限性，这可能解释了缺乏显著结局效应的原因。在此背景下，鉴于我们发现了众多未满足的PC需求，基于TLC模式的干预措施可能使无法获得临终关怀的辅助生活居民及时得到PC服务。进一步探索TLC模式的研究似乎很有必要。
