Molloy D W, Guyatt G H
Department of Medicine, McMaster University, Hamilton.
CMAJ. 1991 Aug 15;145(4):307-11.
To examine the use of and compliance with a new comprehensive health care directive by residents of a home for the aged and to determine the effect of the directive on the use of health care services.
Descriptive study with a before-after design.
A home for the aged providing residential care to women.
All 119 residents (ages 71 to 103 years, mean age 87.5 years).
Introduction of a comprehensive health care directive and follow-up at 1 year.
Residents' treatment choices, compliance with the directive, number of hospital admissions and length of hospital stay, number of deaths and places where deaths occurred.
Ninety (76%) of the residents completed the directive. In the event of reversible life-threatening illness 34, 24, 11 and 21 residents requested supportive, limited, maximum and intensive care respectively. For irreversible illness the numbers were 75, 12, 3 and 0 respectively. In case of cardiac arrest 88% requested that cardiopulmonary resuscitation not be done. In the year before the introduction of the directive there were nine deaths, one in the home and eight in hospitals. In the year after there were 17 deaths, 11 in the home and 6 in hospitals. The mean length of hospital stay was significantly lower in that year than in the year before implementation (p less than 0.001).
This innovative health care directive seems to be feasible, practical and well supported by residents, their families and health care professionals. Further studies are required to establish the generalizability and reproducibility of the data to other elderly people in institutions, to chronically ill patients and to the community at large.
研究一家养老院的居民对一项新的综合医疗保健指令的使用情况及依从性，并确定该指令对医疗服务使用的影响。
前后对照的描述性研究。
一家为女性提供住宿护理的养老院。
119名居民（年龄71至103岁，平均年龄87.5岁）。
引入一项综合医疗保健指令并进行为期1年的随访。
居民的治疗选择、对指令的依从性、住院次数和住院时间、死亡人数及死亡地点。
90名（76%）居民完成了该指令。在出现可逆性危及生命的疾病时，分别有34、24、11和21名居民要求给予支持性、有限性、最大化和强化治疗。对于不可逆性疾病，相应的人数分别为75、12、3和0。在心脏骤停的情况下，88%的居民要求不进行心肺复苏。在引入该指令的前一年有9人死亡，1人在养老院，8人在医院。之后的一年有17人死亡，11人在养老院，6人在医院。该年的平均住院时间显著低于实施指令前一年（p<0.001）。
这项创新的医疗保健指令似乎是可行、实用的，并且得到了居民、其家人和医疗保健专业人员的有力支持。需要进一步研究以确定这些数据对其他机构中的老年人、慢性病患者以及广大社区的普遍性和可重复性。
