Givens Jane L, Kiely Dan K, Carey Kristen, Mitchell Susan L
Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
J Am Geriatr Soc. 2009 Jul;57(7):1149-55. doi: 10.1111/j.1532-5415.2009.02304.x. Epub 2009 May 21.
To describe the medical decisions confronting healthcare proxies (HCPs) of nursing home (NH) residents with advanced dementia and to identify factors associated with greater decision-making satisfaction.
Prospective cohort study.
Twenty-two Boston-area NHs.
Three hundred twenty-three NH residents with advanced dementia and their HCPs.
Decisions made by HCPs over 18 months were ascertained quarterly. After making a decision, HCPs completed the Decision Satisfaction Inventory (DSI) (range 0-100). Independent variables included HCP and resident sociodemographic characteristics, health status, and advance care planning. Multivariable linear regression identified factors associated with higher DSI scores (greater satisfaction).
Of 323 HCPs, 123 (38.1%) recalled making at least one medical decision; 232 decisions were made, concerning feeding problems (27.2%), infections (20.7%), pain (12.9%), dyspnea (8.2%), behavior problems (6.9%), hospitalizations (3.9%), cancer (3.0%), and other complications (17.2%). Mean DSI score +/- standard deviation was 78.4 +/- 19.5, indicating high overall satisfaction. NH provider involvement in shared decision-making was the area of least satisfaction. In adjusted analysis, greater decision-making satisfaction was associated with the resident living on a special care dementia unit (P=.002), greater resident comfort (P=.004), and the HCP not being the resident's child (P=.02).
HCPs of NH patients with advanced dementia can most commonly expect to encounter medical decisions relating to feeding problems, infections, and pain. Inadequate support from NH providers is the greatest source of HCP dissatisfaction with decision-making. Greater resident comfort and care in a special care dementia unit are potentially modifiable factors associated with greater decision-making satisfaction.
描述晚期痴呆养老院（NH）居民的医疗代理人（HCP）面临的医疗决策，并确定与更高决策满意度相关的因素。
前瞻性队列研究。
22家波士顿地区的养老院。
323名晚期痴呆养老院居民及其医疗代理人。
每季度确定医疗代理人在18个月内做出的决策。做出决策后，医疗代理人完成决策满意度量表（DSI）（范围为0 - 100）。自变量包括医疗代理人和居民的社会人口学特征、健康状况以及预先护理计划。多变量线性回归确定与更高DSI分数（更高满意度）相关的因素。
在323名医疗代理人中，123名（38.1%）回忆起至少做出过一项医疗决策；共做出232项决策，涉及喂养问题（27.2%）、感染（20.7%）、疼痛（12.9%）、呼吸困难（8.2%）、行为问题（6.9%）、住院（3.9%）、癌症（3.0%）和其他并发症（17.2%）。DSI分数的平均值±标准差为78.4±19.5，表明总体满意度较高。养老院提供者参与共同决策是满意度最低的方面。在调整分析中，更高的决策满意度与居民住在特殊护理痴呆单元（P = 0.002）、居民更舒适（P = 0.004）以及医疗代理人不是居民的子女（P = 0.02）相关。结论：晚期痴呆养老院患者的医疗代理人最常遇到与喂养问题、感染和疼痛相关的医疗决策。养老院提供者支持不足是医疗代理人对决策不满的最大来源。在特殊护理痴呆单元中让居民更舒适和得到更好的护理是与更高决策满意度相关的潜在可改变因素。
