Ferrand Edouard, Jabre Patricia, Vincent-Genod Claire, Aubry Régis, Badet Michel, Badia Philippe, Cariou Alain, Ellien Françoise, Gounant Valérie, Gil Roger, Jaber Samir, Jay Sylvie, Paillaud Elena, Poulain Philippe, Regnier Bernard, Reignier Jean, Socie Gérard, Tardy Bernard, Lemaire François, Brun-Buisson Christian, Marty Jean
Department of Anesthesiology and Intensive Care, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris, Paris 12 University, 94010 Créteil CEDEX, France.
Arch Intern Med. 2008 Apr 28;168(8):867-75. doi: 10.1001/archinte.168.8.867.
In developed countries at present, death mostly occurs in hospitals, but the circumstances and factors associated with the quality of organization and care surrounding death are not well described.
We designed a large multicenter cross-sectional study to analyze the setting and clinical course of each patient on the day of death. We included 2750 clinical departments of 294 hospitals. Of these, 1033 departments (37.6%) of 200 hospitals (68.0%) contributed to the Mort-a-l'Hôpital survey. Data were collected prospectively by the bedside nurse of each patient within 10 days of the occurrence of death. Main outcome measures included circumstances of death in hospitalized patients; secondary outcomes, nurses' perceptions of quality of end-of-life care.
Of the 1033 participating departments, 420 recorded no deaths during the study period and 613 declared at least 1 death. In the 3793 patients who died and were included for assessment, only 925 (24.4%) had loved ones present at the time of death; 70.1% had respiratory distress during the period before death; and only 12.0% were in pain. Written protocols for end-of-life care were available in 12.2% of participating departments. Only 35.1% of nurses judged the quality of dying and death acceptable for themselves. Principal factors significantly associated with this perception were availability of a written protocol for end-of-life care, anticipation of death, informing the family, surrogate designation, adequate control of pain, presence of family or friends at the time of death, and staff meeting with the family after the death.
This large prospective study identifies nonoptimal circumstances of death for hospitalized patients and a number of suggestions for improvement. A combination of factors reflected in the nurses' satisfaction may improve the quality of end-of-life care.
目前在发达国家，死亡大多发生在医院，但与死亡时的组织质量和护理相关的情况及因素尚未得到充分描述。
我们设计了一项大型多中心横断面研究，以分析每位患者死亡当天的情况和临床过程。我们纳入了294家医院的2750个临床科室。其中，200家医院（68.0%）的1033个科室（37.6%）参与了“医院死亡”调查。数据由每位患者的床边护士在死亡发生后的10天内前瞻性收集。主要结局指标包括住院患者的死亡情况；次要结局为护士对临终护理质量的看法。
在1033个参与科室中，420个科室在研究期间未记录到死亡病例，613个科室宣称至少有1例死亡。在纳入评估的3793例死亡患者中，只有925例（24.4%）在死亡时有亲人在场；70.1%在死前出现呼吸窘迫；只有12.0%处于疼痛状态。12.2%的参与科室有临终护理书面方案。只有35.1%的护士认为自己对死亡过程和死亡质量的接受度尚可。与这种看法显著相关的主要因素包括有临终护理书面方案、对死亡的预期、通知家属、指定代理人、充分控制疼痛、死亡时有家人或朋友在场以及工作人员在患者死后与家属会面。
这项大型前瞻性研究确定了住院患者死亡的不理想情况，并提出了一些改进建议。护士满意度所反映的多种因素相结合可能会提高临终护理质量。
