Casarett David, Karlawish Jason, Morales Knashawn, Crowley Roxane, Mirsch Terre, Asch David A
Center for Health Equity Research and Promotion at the Philadelphia Veterans Affairs Medical Center, Philadelphia, PA, USA.
JAMA. 2005 Jul 13;294(2):211-7. doi: 10.1001/jama.294.2.211.
Hospice care may improve the quality of end-of-life care for nursing home residents, but hospice is underutilized by this population, at least in part because physicians are not aware of their patients' preferences.
To determine whether it is possible to increase hospice utilization and improve the quality of end-of-life care by identifying residents whose goals and preferences are consistent with hospice care.
DESIGN, SETTING, AND PARTICIPANTS: Randomized controlled trial (December 2003-December 2004) of nursing home residents and their surrogate decision makers (N=205) in 3 US nursing homes.
A structured interview identified residents whose goals for care, treatment preferences, and palliative care needs made them appropriate for hospice care. These residents' physicians were notified and asked to authorize a hospice informational visit.
The primary outcome measures were (1) hospice enrollment within 30 days of the intervention and (2) families' ratings of the quality of care for residents who died during the 6-month follow-up period.
Of the 205 residents in the study sample, 107 were randomly assigned to receive the intervention, and 98 received usual care. Intervention residents were more likely than usual care residents to enroll in hospice within 30 days (21/107 [20%] vs 1/98 [1%]; P<.001 [Fisher exact test]) and to enroll in hospice during the follow-up period (27/207 [25%] vs 6/98 [6%]; P<.001). Intervention residents had fewer acute care admissions (mean: 0.28 vs 0.49; P = .04 [Wilcoxon rank sum test]) and spent fewer days in an acute care setting (mean: 1.2 vs 3.0; P = .03 [Wilcoxon rank sum test]). Families of intervention residents rated the resident's care more highly than did families of usual care residents (mean on a scale of 1-5: 4.1 vs 2.5; P = .04 [Wilcoxon rank sum test]).
A simple communication intervention can increase rates of hospice referrals and families' ratings of end-of-life care and may also decrease utilization of acute care resources.
临终关怀可能会改善养老院居民的临终护理质量，但这一群体对临终关怀的利用率较低，至少部分原因是医生不了解患者的偏好。
通过识别目标和偏好与临终关怀一致的居民，确定是否有可能提高临终关怀的利用率并改善临终护理质量。
设计、设置和参与者：对美国3家养老院的居民及其替代决策者（N = 205）进行随机对照试验（2003年12月至2004年12月）。
通过结构化访谈识别出护理目标、治疗偏好和姑息治疗需求使其适合临终关怀的居民。通知这些居民的医生并要求他们批准一次临终关怀信息访问。
主要结局指标为（1）干预后30天内加入临终关怀项目的情况，以及（2）在6个月随访期内死亡居民的家属对护理质量的评分。
在研究样本的205名居民中，107名被随机分配接受干预，98名接受常规护理。与接受常规护理的居民相比，接受干预的居民在30天内更有可能加入临终关怀项目（21/107 [20%] 对1/98 [1%]；P <.001 [Fisher精确检验]），且在随访期内加入临终关怀项目的可能性也更大（27/207 [25%] 对6/98 [6%]；P <.001）。接受干预的居民急性护理入院次数更少（均值：0.28对0.49；P = 0.04 [Wilcoxon秩和检验]），在急性护理机构的住院天数也更少（均值：1.2对3.0；P = 0.03 [Wilcoxon秩和检验]）。与接受常规护理居民的家属相比，接受干预居民的家属对居民护理的评分更高（1 - 5分制的均值：4.1对2.5；P = 0.04 [Wilcoxon秩和检验]）。
一项简单的沟通干预措施可以提高临终关怀转诊率和家属对临终护理的评分，还可能减少急性护理资源的使用。
