Campbell Leslie Anne, Kisely Steve R
Health Outcomes Research Unit, Capital Health District Authority, Centre for Clinical Research, West Annexe, Mackenzie Building, 5790 University Avenue, Halifax, Nova Scotia, Canada, B3H 2E2.
Cochrane Database Syst Rev. 2009 Jan 21;2009(1):CD005963. doi: 10.1002/14651858.CD005963.pub2.
An advance directive is a document specifying a person's preferences for treatment, should he or she lose capacity to make such decisions in the future. They have been used in end-of-life settings to direct care but should be well suited to the mental health setting.
To examine the effects of advance treatment directives for people with severe mental illness.
We searched the Cochrane Schizophrenia Group's Register (February 2008), the Cochrane Library (Issue 1 2008), BIOSIS (1985 to February 2008), CINAHL (1982 to February 2008), EMBASE (1980 to February 2008), MEDLINE (1966 to February 2008), PsycINFO (1872 to February 2008), as well as SCISEARCH and Google - Internet search engine (February 2008). We inspected relevant references and contacted first authors of included studies.
We included all randomised controlled trials (RCTs), involving adults with severe mental illness, comparing any form of advance directive with standard care for health service and clinical outcomes.
We extracted data independently. For homogenous dichotomous data we calculated fixed-effect relative risk (RR) and 95% confidence intervals (CI) on an intention-to-treat basis. For continuous data, we calculated weighted mean differences (WMD) and their 95% confidence interval again using a fixed-effect model.
We were able to include two trials involving 321 people with severe mental illnesses. There was no significant difference in hospital admission (n=160, 1 RCT, RR 0.69 0.5 to 1.0), or number of psychiatric outpatient attendances between participants given advanced treatment directives or usual care. Similarly, no significant differences were found for compliance with treatment, self harm or number of arrests. Participants given advanced treatment directives needed less use of social workers time (n=160, 1 RCT, WMD -106.00 CI -156.2 to -55.8) than the usual care group, and violent acts were also lower in the advanced directives group (n=160, 1 RCT, RR 0.27 CI 0.1 to 0.9, NNT 8 CI 6 to 92). The number of people leaving the study early were not different between groups (n=321, 2 RCTs, RR 0.92 CI 0.6 to 1.6).
AUTHORS' CONCLUSIONS: There are too few data available to make definitive recommendations. More intensive forms of advance directive appear to show promise, but currently practice must be guided by evidence other than that derived from randomised trials. More trials are indicated to determine whether higher intensity interventions, such as joint crisis planning, have an effect on outcomes of clinical relevance.
预先医疗指示是一份文件，规定了一个人在未来丧失做出此类决策的能力时对治疗的偏好。它们已被用于临终关怀环境中指导护理，但也应非常适用于心理健康环境。
研究预先治疗指示对重度精神疾病患者的影响。
我们检索了Cochrane精神分裂症研究组注册库（2008年2月）、Cochrane图书馆（2008年第1期）、BIOSIS数据库（1985年至2008年2月）、CINAHL数据库（1982年至2008年2月）、EMBASE数据库（1980年至2008年2月）、MEDLINE数据库（1966年至2008年2月）、PsycINFO数据库（1872年至2008年2月），以及SCISEARCH数据库和谷歌搜索引擎（2008年2月）。我们查阅了相关参考文献，并联系了纳入研究的第一作者。
我们纳入了所有随机对照试验（RCT），这些试验涉及患有重度精神疾病的成年人，比较了任何形式的预先指示与标准医疗服务及临床结局的护理。
我们独立提取数据。对于同质二分数据，我们在意向性分析的基础上计算固定效应相对风险（RR）和95%置信区间（CI）。对于连续数据，我们再次使用固定效应模型计算加权平均差（WMD）及其95%置信区间。
我们能够纳入两项涉及321名重度精神疾病患者的试验。在接受预先治疗指示或常规护理的参与者之间，住院率（n = 160，1项RCT，RR 0.69，95%CI 0.5至1.0）或精神科门诊就诊次数没有显著差异。同样，在治疗依从性、自我伤害或逮捕次数方面也没有发现显著差异。与常规护理组相比，接受预先治疗指示的参与者需要的社会工作者时间更少（n = 160，1项RCT，WMD -106.00，95%CI -156.2至-55.8），并且预先指示组的暴力行为也较少（n = 160，1项RCT，RR 0.27，95%CI 0.1至0.9，NNT 8，95%CI 6至92）。两组提前退出研究的人数没有差异（n = 321，2项RCT，RR 0.92，95%CI 0.6至1.6）。
现有数据太少，无法给出明确的建议。更强化形式的预先指示似乎显示出前景，但目前的实践必须以随机试验以外的证据为指导。需要更多试验来确定更高强度的干预措施，如联合危机规划，是否对具有临床相关性的结局有影响。
