Volandes Angelo E, Paasche-Orlow Michael K, Barry Michael J, Gillick Muriel R, Minaker Kenneth L, Chang Yuchiao, Cook E Francis, Abbo Elmer D, El-Jawahri Areej, Mitchell Susan L
General Medicine Unit, Department of Medicine, Massachusetts General Hospital, 50 Staniford Street, Boston, MA 02114, USA.
BMJ. 2009 May 28;338:b2159. doi: 10.1136/bmj.b2159.
To evaluate the effect of a video decision support tool on the preferences for future medical care in older people if they develop advanced dementia, and the stability of those preferences after six weeks.
Randomised controlled trial conducted between 1 September 2007 and 30 May 2008. Setting Four primary care clinics (two geriatric and two adult medicine) affiliated with three academic medical centres in Boston.
Convenience sample of 200 older people (>or=65 years) living in the community with previously scheduled appointments at one of the clinics. Mean age was 75 and 58% were women.
Verbal narrative alone (n=106) or with a video decision support tool (n=94).
Preferred goal of care: life prolonging care (cardiopulmonary resuscitation, mechanical ventilation), limited care (admission to hospital, antibiotics, but not cardiopulmonary resuscitation), or comfort care (treatment only to relieve symptoms). Preferences after six weeks. The principal category for analysis was the difference in proportions of participants in each group who preferred comfort care.
Among participants receiving the verbal narrative alone, 68 (64%) chose comfort care, 20 (19%) chose limited care, 15 (14%) chose life prolonging care, and three (3%) were uncertain. In the video group, 81 (86%) chose comfort care, eight (9%) chose limited care, four (4%) chose life prolonging care, and one (1%) was uncertain (chi(2)=13.0, df=3, P=0.003). Among all participants the factors associated with a greater likelihood of opting for comfort care were being a college graduate or higher, good or better health status, greater health literacy, white race, and randomisation to the video arm. In multivariable analysis, participants in the video group were more likely to prefer comfort care than those in the verbal group (adjusted odds ratio 3.9, 95% confidence interval 1.8 to 8.6). Participants were re-interviewed after six weeks. Among the 94/106 (89%) participants re-interviewed in the verbal group, 27 (29%) changed their preferences (kappa=0.35). Among the 84/94 (89%) participants re-interviewed in the video group, five (6%) changed their preferences (kappa=0.79) (P<0.001 for difference).
Older people who view a video depiction of a patient with advanced dementia after hearing a verbal description of the condition are more likely to opt for comfort as their goal of care compared with those who solely listen to a verbal description. They also have more stable preferences over time.
Clinicaltrials.gov NCT00704886.
评估视频决策支持工具对老年人若患晚期痴呆时未来医疗护理偏好的影响，以及六周后这些偏好的稳定性。
2007年9月1日至2008年5月30日进行的随机对照试验。地点：波士顿三个学术医疗中心附属的四家初级保健诊所（两家老年医学诊所和两家成人医学诊所）。
200名社区老年人（≥65岁）的便利样本，他们之前已在其中一家诊所预约就诊。平均年龄为75岁，58%为女性。
仅口头叙述（n = 106）或结合视频决策支持工具（n = 94）。
首选的护理目标：延长生命护理（心肺复苏、机械通气）、有限护理（住院、使用抗生素，但不包括心肺复苏）或舒适护理（仅进行缓解症状的治疗）。六周后的偏好。分析的主要类别是每组中首选舒适护理的参与者比例差异。
在仅接受口头叙述的参与者中，68人（64%）选择了舒适护理，20人（19%）选择了有限护理，15人（14%）选择了延长生命护理，3人（3%）不确定。在视频组中，81人（86%）选择了舒适护理，8人（9%）选择了有限护理，4人（4%）选择了延长生命护理，1人（1%）不确定（χ² = 13.0，自由度 = 3，P = 0.003）。在所有参与者中，与更倾向于选择舒适护理相关的因素包括大学毕业及以上学历、健康状况良好或更好、健康素养较高、白人种族以及被随机分配到视频组。在多变量分析中，视频组的参与者比口头组的参与者更有可能选择舒适护理（调整后的优势比为3.9，95%置信区间为1.8至8.6）。六周后对参与者进行了再次访谈。在口头组接受再次访谈的94/106（89%）名参与者中，27人（29%）改变了他们的偏好（kappa = 0.35）。在视频组接受再次访谈的84/94（89%）名参与者中，5人（6%）改变了他们的偏好（kappa = 0.79）（差异P<0.001）。
与仅听口头描述的老年人相比，在听到对晚期痴呆病情的口头描述后观看患者视频描述的老年人更有可能选择舒适护理作为他们的护理目标。随着时间推移，他们的偏好也更稳定。
Clinicaltrials.gov NCT00704886
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